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Funding Case study - Standing Wheelchairs and Frames
Study on the Benefits of Standing Wheelchairs and Standing Devices
Clinical experience suggests that wheelchair users often experience painful, problematic
and costly secondary complications due to long term sitting. Standing is an effective way
to counterbalance many of the negative effects of constant sitting 1,2. Standers integrated
into wheelchair bases enhance the beneficial effects of standing since they allow for more
frequent, random and independent performance of standing than in persons who use
standing devices outside of a wheelchair base. Integration of this feature into the
wheelchair base also enables standing to enhance functional activities.
It is RESNA’s position that wheelchair standing devices are often medically necessary, as
they enable certain individuals to:
- Improve functional reach in ADLs (i.e. grooming, cooking, reaching)
- Enhance independence and productivity
- Maintain vital organ capacity
- Reduce the occurrence of Urinary Tract Infections
- Maintain bone mineral density
- Improve circulation
- Improve passive range of motion
- Reduce abnormal muscle tone and spasticity
- Reduce the occurrence of pressure sores
- Reduce the occurrence of skeletal deformities, and
- Enhance psychological well-being.
Special precautions must be exercised when utilizing standers, in order to avoid the risk of injury, such as fractures. A licensed medical professional (i.e. physical or occupational therapist) must be involved with the assessment, prescription, trials and training in the use of the equipment. The purpose of this document is to share typical clinical applications as well as provide evidence from the literature supporting the application of this seat function to assist practitioners in decision making and justification. It is not intended to replace clinical judgment related to specific client needs.
Definition
A standing feature integrated into a wheelchair base allows the user to obtain a standing position without the need to transfer from the wheelchair. A mechanical or electromechanical system manipulated via levers or the wheelchair’s controls moves the seat surface from horizontal into a vertical or anteriorly sloping position while maintaining verticality of the legrests and backrest, thus extending the hip and knee joints. A full vertical standing position can be achieved directly from sitting, or through gradual angle changes from a laying position, or a combination of these p ositions. Most wheelchair standers allow for full or partial extension of the hip and knee joints, and full upright or partially tilted positions. Wheelchair standers are available on manual or power wheelchair bases.
Wheelchair standing devices address the following medical needs:
Functional reach and access to ADLs
Standing adds significant amount of vertical access. Since the seating surface moves into a vertical position, typically the amount of additional vertical access equals the user’s seat depth. This allows people to access kitchen cabinetry, light switches, microwaves, mirrors, sinks, hangers, thermostats, medicine cabinets, and many other surfaces to enhance their abilities to perform ADLs, depending on the client’s upper extre mity function. An integrated wheelchair stander system allows for moving about while in a standing position, and standing can become an integral and functional part of the day and the user can perform a variety of ADLs while in the standing position, combining
functional and medical benefits. A standing position can be assumed as needed, both for indoors and outdoors activities – it can aid productivity and integration at work, school, church, or enhance independence for example when shopping for groceries. Being able to perform standing from one’s wheelchair also minimizes transfers, thereby enhancing safety, conserving energy and reducing dependency. Research suggests that in addition to expense and lack of awareness, the major reasons for not using stationary standers for wheelchair users with Spinal Cord Injury (SCI) is time constraints, lack of assistance, and/or lack of space for an extra device.
Passive Range of Motion, Contractures
Standing extends the hip and knee joint to provide position change. Animal studi es have
shown that muscles which were fixed in a flexed position resulted in increased
contractures of the joints, especially when the bones are still growing 3,4. Many people in
wheelchairs have limited access to therapy or care givers who can provide the necessary
amount of ranging – standers integrated with the wheelchair base allow them to perform
this important activity on their own and with higher frequency. Standing, however,
should not be considered as a substitute for therapy.
Vital organ capacity
During standing, the pelvis tends to assume a more anterior tilt or neutral position,
allowing for an increase in lumbar lordosis as compared to sitting. This in turn helps
establish a better alignment of the spine and extend the upper trunk. Extension of the
upper trunk results in reduced pressure on the internal organs, thereby enhancing
respiratory and gastro-intestinal capacity and functioning. This can prevent or delay many
secondary complications so often seen in wheelchair users.
Respiration
Many users experience improved lung capacity when standing often.
Studies have shown that those who stand frequently in standing power
wheelchairs have lesser or delayed occurrence of respiratory complications and
improved respiratory volume 2. Standing can help also reduce congestion and coughing 5.
Gastro -Intestinal problems. Standing wheelchairs users also experienced lesser or
delayed occurrence of gastro-intestinal complications , for example via
improvement in gastric emptying.
Bowel function
Some users have experienced improved bower regularity, reduced
constipation, and lesser occurrence of accidental and unregulated bowel
movement as a consequence of using wheelchair standers1. Elimination of chronic
constipation and significant reduction in bowel care time has also been shown as a
resul t of frequent standing 2,6. Chronic constipation can lead to bowel obstruction,
a dangerous condition often requiring surgery. Unregulated bowel movements can
lead to fecal incontinence at a time when the client cannot be cleaned by a
caregiver, increasing the risk of developing pressure sores.
Increased Bladder emptying
Users of standing devices reported that they were able to empty their bladders more completely than prior to using the device 1.
Urinary Tract Infections
Urinary Tract Infections (UTI ) is the third most frequent complication for clients with
SCI 7, and a frequent secondary complication for many other wheelchair users. Prolonged
immobility causes hypercalcemia, increased urinary calcium output 8, and also reduces
bladder emptying 1. By reducing contributing risks, standing wheelchairs have been
shown to reduce the occurrence of UTI for wheelchair users 1, which could lead to kidney infections.
Bone Mineral Density
Many wheelchair users experience significant reduction in Bone Mineral Density (BMD)
due to the lack of weight bearing in the lower extremities. In fact, without gravitational or
mechanical loading of the skeleton, there is a rapid and marked loss of bone. This results
in osteoporosis and risk of fractures. Research suggests that weight bearing is superior to
nutritional supplements in preventing BMD loss, and that the mechanical loading of the
bones should be dynamic for full prevention of BMD loss. It also appears th at with
discontinuation of the weight bearing program, BMD levels will continue to decrease
and/or return to pre-weight bearing values. While stationary standers lessen the loss of BMD, wheelchair standers may actually eliminate BMD loss all together, given their ability to provide dynamic weight bearing
through the lower extremities. Populations with a variet y of disabilities have been studied
for loss of BMD, such as children with Cerebral Palsy (CP) or Spina Bifida, as well as
adults with Stroke, Multiple Sclerosis and SCI 9. Even if BMD loss has not yet occurred
in a user, standing can be an effective mean to help prevent this secondary complication.
Loss of BMD. Review studies establish the direct relationship between
weightlessness and loss of BMD, as well as the relationship between osteoporosis
and the high risk of fractures 10-12. Studies with astronauts and people in bedrest
quantify the negative effect of weightlessness and lack of weightbearing on BMD 13- 17.
This loss can be as high as 36% loss of the cross sectional area of a non-
weight bearing bone within a month 18. In bed rest, the average urinary calcium
loss at the peak is about -150 mg per day, which corresponds to 0.5 percent of
total body calcium 19-21. For people with disabilities, numerous studies point out
the benefits of frequent passive standing and weight bearing/exercise on BMD 22- 25.
Fractures and loss of independence. Loss of BMD leads to osteoporosis and the
consequent risk of fractures. Articles on children with Osteogenesis Imperfecta
recommend frequent standing in childhood to maximize adulthood ind ependence
by minimizing fractures and the likelihood of broken bones 26,27. Many people
with disabilities often heal slower, as well. Fractures may limit short and long term function.
Supplements. Evidence suggests that while appropriate nutritional supplements
may reduce calcium loss from the bones, mechanical loading is s uperior to
supplements for BMD maintenance18. Dietary changes, such as increased intake
of calcium and/or vit amin D, have not proven effective at minimizing disuse bone loss 28.
Mechanical weight loading. Living bones constantly adapt themselves to the
mechanical forces applied to them, and their structure is directly linked to their
weight bearing activity and forces occurring due to movement against
resistance29. Weight-bearing activity can be thought of as any activity that is done
while upright, requiring the bones to partially or fully support the body's weight
against gravit y 30. Impact-loading, weight -bearing activity, therefore, involves
some impact or force being transmitted to the skeleton during weight bearing.
Standing provides mechanical loading through the longitudinal axes of the lower
extremity bones. When the body is upright and extended, the bones of the lower
extremities carry the entire weight of the body therefore loading is most efficient.
Since the lower extremities normally carry the entire body’s weight, they are the
most prone to bone degeneration due to reduced or limited weight bearing.
Dynamic loading. Further studies clarify that standing is to be dynamic (higher
multitude and varied magnitude), in order to fully prevent loss of BMD.
According to the scientific literature, static loading is less efficient than dynamic
loading in prevent ion of BMD loss 18, 31-34. A recent study of children with
disabling conditions found that a 6 months standing program with a stationary
stander still resulted in BMD reduction (-6.3%) , while utilizing vibrating plates
underneath the standers actually increased BMD (+11.9%) in the subjects 35. This
is of utmost importance regarding standing wheelchairs , since they offer dynamic
loading in a variet y of ways. When using a mobile wheelchair base during
standing, vibration occurs due to the movement of the whee lchair applying
dynamic loads to the bones of the lower extremities. In addition, small obstacles
(such as carpet edges, door thresholds, tile edges, etc.) all provide dynamic input
when the user drives over them. Standers integrated with a wheelchair base also
allow for frequent loading of the bones throughout the day by just performing partial standing.
Maintenance of weight bearing. For the weight bearing exercise to be effective,
the mechanical stress placed on the bone must exceed the level to which t he bone
has adapted (i.e., short periods of intense loading can produce more new bone
than long-term routine loading) 36. However, long-term routine loading is
important in maintaining bone density. And although bone responds to
mechanical loading, it is easier to lose bone through inactivity than to gain more
through changes in functional loading. When weight -bearing exercise is not
continued, bone mass reverts to pre-training levels 37, 38. With standers integrated
into a wheelchair base, the user is not dependent on circumstances (such as
caregiver availability) to continue standing. Consequently, maintenance of a
standing program and higher frequency of standing is more likely. Additionally,
integrated standers allow for standing nearly any time for any length of time,
therefore weight loading is more likely to be of random distribution, which
appears to be superior in BMD loss prevention.
Circulation
Users have also experienced improvement in lower extremity circulation as a
consequence of utilizing a wheelchair stander 2. Some benefits are reduced swelling in the legs and feet.
Tone
Wheelchair standers also aid in reduction of access muscle tone; research indicates that
muscle stretch combined with wei ght loading reduces muscle tone more than stretching
alone (32% vs. 17%) 39. Some users experience tone reduction in their upper extremities
due to better skeletal alignment in a standing position. This may translate into improved
speech and better hand and arm function to perform ADLs. Tone reduction can improve
comfort, minimize further range of motion losses, improve function and conserve energy.
Spasticity
Research studies show that standing wheelchair users have experienced significant
reduction in spasticity 1,2. This helps with transfers, can aid in better sleep, reduces
fatigue and pain, and improves positioning in the wheelchair. Standing has an immediate
and significant effect on spasticity 40.
Pressure sores
When fully standing, pressure is 100% relieved off the Ishial Tuberosities (ITs).
However, when tilting or reclining, there is only partial redistribution of pressure
underneath the ITs 41, 42. Pressure ulcers are the primary complication for people with SCI ,
and many other adults who sit in wheelchairs all day long. There is evidence that users
have suffered fewer pressure sores while using standers 41, or integrated wheelchair standers1,2.
Skeletal deformities
Clinical experience suggests that e xtension of the upper trunk and proper alignment of
the hip during standing helps de lay typical skeletal deformities often seen in people who
sit in a wheelchair for long periods of time, such as fixed posterior pelvic tilt, kyphosis
and scoliosis of the spine, and windswept deformities of the lower extremities. During
standing the head of the femur usually ends up better seated in the acetabulum, which is
important especiall y for children, to promote healthy skeletal alignment, as well as to
promote proper development of the acetabular socket.
Community environments, vocational and recr eational benefits
Integrated wheelchair standers can benefit user s in a variet y of community settings to
enhance their independence, improve vocational, and enable recreational activities.
Examples include but are not limited to:
Improve ability to reach higher shelves in grocery stores and other shopping facilities
Ability to access vending machines, payphones, high elevator buttons, coffee shop counters, etc.
Stand up to access fax machines, drawers, client files, and other necessities at work
Enable cer tain jobs which need to be performed from a standing position (such as
hotel receptionist, clerical, medical, hair st ylist, etc.)
Enhance recreational activities, for example by standing up with others on a ball game.
Additional benefits
Additional benefits of utilizing an integrated wheelchair standing system include but are not limited to:
Reduce fatigue due to benefits mentioned earlier, thereby prolonging tolerance to
staying in the wheelchair for longer periods of time
Enable some male users to use a public urinal independently as opposed to
transferring to a toilet or using catheterization
Reduce the need for attendant care by lessening the need to transfer in and out of
the wh eelchair, the ability to range independently and perform ADLs
Reduce back pain and risk of injury for caregivers by minimizing the amount of
transfers they need to perform
Partial standing provides an anteriorl y sloped femur position, which can translate
into a better pelvic alignment and enhanced lumbar lordosis. Clinical exp erience
suggests that some clients find this position to improve their alertness and/or improve their upper extremity function.
Many children who use mobility equipment throughout the day are on intensive
standing programs. They often have a stander at school and one at home.
Integrating standing into the wheelchair base reduces the necessary number of
equipment, and ensures more frequent and independent initiation of standing.
Standing up with a tilt table function (gradual angle change into upright) may help
alleviate problems with orthostatic hypotension, especiall y with clients after prolonged bedrest.
Psycho-social indications
A standing position can lend wheelchair users a heightened sense of confidence and
equality, by enabling eye to eye convers ations with the non-disabled society. Many
everyday and special occasions in our society require standing; citing of the Pledge of
Allegiance at school, graduations, weddings, demonstrations, introductions to people,
religious services, etc. When a person is allowed to stand with everyone else any time
(afforded by an integrated wheelchair standing device) there is a much better sense of
integration and the disability becomes less visible, self-esteem is enhanced, acceptance
by others is perceived to be higher, and depression is often reduced.
Contraindications
In spite of the numerous benefits, a standing wheelchair might be contraindicated without
appropriate assessment. Not everybody is an appropriate candidate for standing. Some
contraindications and precautions include but are not limited to:
Existing contractures: the client may benefit from partial weight bearing even if
he already has fixed contractures of the lower extremities. However, the amount
of extension may have to be limited mechanically or electronically, especially in
case of a client without sensation. A wheelchair stander is a powerful device and
may cause harm if attempting to overstretch contracted muscles.
Skeletal deformities: both the sitting and the standing position have to provide
appropriate support for stability and function, so special accommodations may
have to be provided for people with significant deformities, especiall y if those
deformities are not flexible. Skeletal alignment is to be carefully observed while standing.
If the client has not been standing for a significant amount of time (schedules vary
by person and circumstances) , it is necessary to obtain a physician’s approval and
trial a stander to assess standing tolerance. Prior examinations might be
warranted, such as X-rays and bone density assessment.
Existing BMD loss and osteoporosis might cause fractures if attempting to stand
prematurely and without a well designed progressive standing program.
Postural hypotension: check for blood pressure and dizziness while standing up, especiall y for new clients with recent injuries. Some amount of sacral shearing might occur while standing up or sitting down – attention must be paid to skin integrity in the sacral region.
Adaptive or custom seating: standing systems will not work with one piece
seating systems (as the seat to back angle changes) or highly contoured seating
systems due to shear.
Frequency of standing
Frequency and duration of standing routines are recommended on an individual basis.
They very by tolerance, fatigue, level of current BMD and functional goals. In general,
standing is recommended as long and as often as the user can tolerate comfortably to
increase the benefits. Standers integrated into wheelchair bases allow for spontaneous and
frequent utilization of standing.
Summary
It is RESNA’s position that wheelchair standing devices are medically beneficial for
wheelchair users by: enabling them to reach; improving ADL abilities; enhancing
independence and productivity; maintaining vital organ capacit y, bone mineral density,
circulation and range of motion; reducing tone and spasticity, the occurrence of pressure
sores and skeletal deformities ; and enhancing psycho-social well-being.
Case Examples
JD is a 19 year old male with spastic athetoid quadriplegic Cerebral Palsy. He has been
driving a power wheelchair for mobility since he was 6. A power wheelchair with a
standing feature was prescribed to him, due to the need for frequent standing, functional
goals, to enhance independen ce and to reduce his mother’s back pain which she has
developed due to frequent transfers. After 6 months of use a marked improvement is
noticed in his upper extremity function, his speech and swallowing, as well as his comfort
and tolerance to staying in the wheelchair all day.
Larry is a 65 year old gentleman with Multiple Sclerosis for the last 15 years. On initial
evaluation he was experiencing significant problems with lower extremity spasticity that
interfered with his ability to sit in a wheelchai r and to be transferred with the assistance
of his wife. He was using a manual wheelchair with a limited seating system and was
developing a severe kyphosis of the spine. He also had issues with bowel and bladder
control, lower ext remity edema, and poor affect. Following careful assessment and an
extensive trial of a stander, he was provided with a power wheelchair equipped with a
passive stander as well as tilt in space, reclining back rest, and elevating legrests. At a six -
month follow-up assessment he reported standing 4 to 6 times per day for 15 to 30
minutes. He was observed to have significantly decreased lower extremity spasticity to
the point where he was no longer taki ng anti-spasticity medication. His wife reported this
further made transferring him safer and more manageable. It also allowed him to have
improved bed mobility that allowed him to get a full night’s sleep. There was also no
noted edema in his lower extremities and he reported far fewer bowel and bladder
accidents to the point where he was comfortable going out in the community on a weekly
basis. He demonstrated improved ability to reach and carry out tasks at different surface
heights, was observed to be able to sit more upright with less a kyphosis, and improved
affect.
Mr. D. is a 36 year old male with a diagnosis of tetraplegia due to a C7 spinal cord injury.
He is the primary caretaker of two young boys and works part time as a barber. In the
community, he utilizes a rigid frame wheelchair. A manual wheelchair with standing
feature was prescribed for him due to severe complaints of shoulder and upper quadrant
pain and decreased upper extremity function. This was due to repeated overhead
activities at home and work. With the manual wheelchair with standing feature he was
able to work for longer periods of time and care for his children. The standing feature
allowed D to complete activities in his forward plane. This led to a significant decrease in
complaints of shoulder pain and improved upper extremity function.
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in patients with spastic paraplegia. Scandinavian Journal of Rehabilitation Medicine. 13(4):117-21, 1981.
Experimental study on the effects of stretching with or without weight loading in paraplegic patients. Level III .
40. Bohannon RW. Tilt t able standing for reducing spasticity after spinal cord injury.
Archives of Physical Medicine & Rehabilitation. 74(10):1121-2, 1993 Oct.
Case study with a single client with SCI on the effect of tilt table use on spasticity. Level V.
41. Hobson D.A. (1992). Comparative effects of posture on pressure and shear at the
body-seat interface. J Rehabil Res Dev. Fall;29(4):21-31.
Experimental study on tilt-recline systems and their effect on pressure. Level III .
42. Aissaoui, R., Lacoste, M., Dansereau, J. Analysis of sliding and pressure
distribution during a repositioning of persons in a simulator chair. IEEE
Transactions on Neural Systems and Rehabilitation Engineering 2001; 9: 215- 224.
Experimental study on repositioning and its effect on pressure. Level IV.
43. Janice T. Hunt MS, PT (1993). Standing Tall, Team Rehab, Sept. 17-20
Case study description of a client utilizing a standing wheelchair. Level V.
Sackett model definition of levels:
Level I: Evidence is obtained from meta-analysis of multiple, well -designed, controlled studies.
Level II: Evidence is obtained from at least one well -designed experimental study.
Level III: Evidence is obtained from well -designed, quasi-experimental studies such as non- randomized, controlled
single -group, pre-post, cohort, time, or matched case -control series
Level IV: Evidence is from well -designed, nonexperimental studies such as comparative and correlational descriptive and case studies
Level V: Evidence from case reports and clinical examples
RESNA Position on the Application of Wheelchair Standing Devices
Authors:
Julianna Arva, M.S., ATP, Ginny Paleg, PT, Michelle Lange, OTR, ABDA, ATP, Jenny
Lieberman, MSOTR/L, ATP, Mark Schmeler, M.S., OTR/L, ATP, Brad Diciano, MD, Mike Babinec,OTR/L, ABDA, ATP
RESNA is an interdisciplinary association of people with a common interest in
technology and disability. RESNA’s purpose is to improve the potential of people with
disabilities to achieve their goals through the use of technology. RESNA serves that
purpose by promoting research, development, education, ad vocacy and provision of
technology; and by supporting the people engaged in these activities.
Developed through RESNA’s Special Interest Group in Seating and Wheeled Mobility
