4/20/15  

STANDING WHEELCHAIRS: EXAMINING THE EVIDENCE

•  Iden,fy  three  relevant  pa,ent  applica,ons  of  wheelchair   standers  based  on  research.   •  Verbalize  understanding  of  the  purpose  of  using  evidence  in   jus,fying  the  need  for  wheelchair  standing  devices.   •  List  three  benefits  to  integra,ng  a  standing  feature  into  a   client s  wheelchair  base.   •  Iden,fy  three  poten,al  medical  benefits  of  standing.  

•  Standing  wheelchairs  are  too  difficult  to   jus,fy  for  funding.   •  There  are  no  differences  between  a   standing  wheelchair  and  separate   standing  frame. •  “Sorry,  it’s  been  too  long  since  you’ve   stood  so  a  standing  wheelchair  is   contraindicated.”  

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Truth is . . . •  •  •  •  •  • 

Lack  of  knowledge   Lack  of  resources   Lack  of  perseverance   Lack  of  desire   Lack  of  commitment   Lack  of  insight  

•  Three  Main  Reasons   –  Health  Benefits   –  Func,onal  Benefits   –  Social  Benefits  

www.medscape.com

•  ATer  6  weeks  of  bed  rest     –  Decreased  Bone  Mineral  Density  (BMD)   –  Risk  of  Pressure  Ulcers   –  Development  of  Joint  Contractures   –  Impaired  bowel  and  bladder  func,oning   –  Impaired  respiratory  func,oning   –  Gastro-­‐Intes,nal  problems     Deitrick  J,  Whedon  G,  Shorr  E.  Effects  of  immobiliza,on  upon  various  metabolic  and   physiologic  func,ons  of  normal  men.  American  Journal  of  Medicine,  1948;  4:  3.  

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•  Study by the American Cancer Society followed 123,216 individuals from 1993-2006. –  Women who were inactive and sat over 6 hours a day were 94% more likely to die during the time period studied than those who were physically active (68% for men). –  These findings were INDEPENDENT of physical activity levels (negative effects were just as strong in individuals who exercised regularly).

•  Spinal Cord Injury (SCI) •  Spina Bifida

•  Brain Injury •  Stroke (CVA) •  Cerebral Palsy (CP)

http://www.juststand.org/ tabid/674/language/en-us/ default.aspx

Should NOT be diagnosis driven… Anyone who is unable to change their body position nor stand upright on their own may be a candidate for a standing device.

•  Neuromuscular Diseases •  •  •  • 

Primary Lateral Sclerosis (PLS) Muscular Dystrophy (MD) Spinal Muscular Atrophy (SMA) Multiple Sclerosis (MS)

(Andriaasen, Asbeck, Lindeman, vand der Woude, de Groot, & Post, 2013)

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Evidence Based Practice (EBP)

Current Research

+

Clinical Experience

=

Best Practice

•  Best comprehensive overall summary of research examining wheelchair standers. •  Recently updated - 2013 (Current State of Literature) •  Benefits, Indications, Contraindications, Case Studies (CP, MS, SCI) •  Available online for download www.resna.org

•  Bone Mineral Density –  Dynamic Weight Bearing – Shorter, More Frequent

•  GI/Respiratory/Circulatory –  Frequency of Standing

•  Bowel/Bladder –  Reducing UTI/kidney stones/constipation/bowel accidents

•  Spasticity –  Immediate and significant effect

•  Contractures –  Providing prolonged stretch

•  Pressure Management –  Reduced frequency when using stander – Best pressure relief overall 1 7

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SCI triggers rapid loss of BMD in both the trabecular bone and cortical cross sectional area (shaft of the bone). •  Studies have shown that as much as 15%-35% BMD in the LEs was lost during the first year post injury. •  Steady state reached at 4 years post SCI at ~50% BMD of healthy controls. (Dudley-Javoroski & Shields, 2012)

•  54 subjects divided into 2 groups: –  Standing –  Non-Standing

•  After 1st year: LE BMD decreased 19.62% (standing); 24% (non-standing) •  After 2 years: Standing group had significantly higher BMD than non-standing group Conclusion: SCI patients who stood at least 1 h/day; at least 5 days/week, had significantly higher BMD in the lower extremities after 2 years compared to patients who did not perform standing. (Alekna, Tamulaitiene, Sinevicius, & Juocevicius, 2008)

•  n=38 (standing group) / n=15 (nonstanding) versus healthy controls •  BMD in lumbar spine and femur decreased in all individuals with SCI as compared to controls •  Standing vs. non-standing: Standing group had improved BMD in the lumbar spine (Goemaere, Van Laere, De Neve, & Kaufman, 1994)

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Non-ambulant children and adults with CP are prone to low trauma fractures. This is thought to be due to decreased BMD. •  Longer standing programs improved vertebral BMD. No significant affect on proximal tibial BMD. (n=26) emsstaff.buncombecounty.org

(Caulton, Ward, Alsop, Dunn, Adams, & Mughal, 2004)

•  Chart review (n=482) for patients with acute SCI admitted between 1990-1995. •  44 patients (9%) developed contractures during initial hospitalization. –  30 Tetraplegic; 14 Paraplegic –  Pressure Ulcer – more likely (14.1%) –  Spasticity – more likely (12.7%) –  Co-existent or suspected head injury (15%) (Dalyan, Sherman, Cardenas, 1998)

•  n= 6; Dx: Secondary Progressive MS •  Pilot Study - Compared daily standing x30 min. for 3 weeks and an exercise program for a 3-week period. –  Subjects were their own controls

•  Significant ankle and hip ROM improvements in standing compared to exercise. •  No significant difference in spasticity between groups (downward trend noted with standing). (Baker, Cassidy, & Rone-Adams, 2007)

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•  Patients with Stroke - Spastic Hemiplegia (n=17) •  Single session prolonged calf muscle (triceps surae) stretch x 30 min. on tilt table •  Significant improvement in dorsiflexion ROM as well as increased motor neuron excitability of tibialis anterior. (Tsai, Yey, Chang, Chen, 2001)

•  Single Case - T12 SCI •  Tilt table used 5 non-consecutive days •  Immediate and significant effect on spasticity lasting until the following morning •  Particularly useful to improve car transfers •  Indication for wheelchair stander allowing management of spasticity when needed (Bohannon, 1993)

•  4 subjects with SCI (T6, T5-6, C2-5, C5) completed 12-wk exercise with dynamic weight bearing (DWB). •  Surface EMG, HR, BP measured throughout •  Conclusion: Exercise during DWB can induce positive physiologic and neuromuscular responses and may serve as preparation for more advanced rehabilitation. (Edwards & Layne, 2007)

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•  Single case study - 62 y/o male with T12L1 ASIA B paraplegia •  Injured in 1965 - chronic constipation •  Standing table 5x/week - 1 hour duration •  Significant increase in frequency of BM’s •  Significant decrease in bowel care time (Hoenig, Murphy, Galbraith, Zolkewitz, 2001)

•  •  •  •  • 

8 men; 2 women (Range: 19-56 y/o) n=10. Incomplete C5-C7 SCI 6 - Early Group (within 6 months post SCI) 5 - Late Group (12-18 months post SCI) Compared tilt table (at least 20 min) with strengthening exercises •  Both groups – tilt table greater impact on Calcium balance in urine than strengthening –  Early group with more significant results (Kaplan, Roden, Gilbert, Richards, & Goldschmidt, 1981)

•  Patients in ICU who had been intubated and mechanically ventilated more than 5 days (n=15) •  Tilt table to 70 degrees x 5 minutes •  Significant improvement in respiratory parameters during and immediately after tilt table. •  Not present 20 minutes later. (Chang, Boots, Hodges, Thomas, Paratz, 2004)

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•  Compared tilt, recline, and standing - looking at seat and backrest pressure –  6 Able-Bodied (AB) and 10 Subjects with SCI

•  Maximum decreases in seat pressure in full standing and full recline. Standing reduced both seat and backrest pressure.

(Sprigle, Mauer, & Sorenblum, 2010)

Edlich et al. (2004) recommends power wheelchair standing for those who are able to tolerate weight bearing for prevention and treatment of pressure ulcers.

•  What are the recommended guidelines for performing pressure relief? •  How many hours do you think the average power wheelchair user spends in the chair? •  How often do you think the users tilt their chair? •  How often do you think the users tilt their chair to relieve pressure? (Sonenblum & Sprigle, 2011)

•  How often does one need to stand in order to experience the benefits? –  3 days/week? 5 days/week? Everyday?

•  For how long? –  1 hour? 30 minutes?

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•  Review study in 2013 stated that children with neuromuscular dysfunction could benefit from standing 5 days/week –  Improve BMD: 60-90min/day –  Improve hip biomechanics: 60min/day in 30-60 degrees of hip abduction –  Improve ROM: 45-60 min/day –  Minimize spasticity: 30-45 min/day

(Paleg, Smith, & Glickman, 2013)

•  A 2010 review study of supported standing programs for both pediatric and adult neuromuscular populations •  Goal Dosage: total of 1 hour - 5 days/ week –  BMD: moderately strong evidence –  Decreasing hypertonicity: some support –  ROM: some support –  Whole body vibration: promising trend but inconclusive (Glickman, Geigle, & Paleg, 2010)

•  “Loading delivered in a manner that subjects could administer themselves was useful in alleviating the normally occurring decline in BMD.” •  “Frequent low-intensity strains build BMD” (Dudley-Javorski & Shields, 2008)

•  High frequency and low level mechanical stimuli were capable of augmenting bone mass and morphology. (Rubin, Sommerfeldt, Judex, & Qin, 2001)

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•  Right forelimbs of adult rats loaded 360 cycles, 3 days/week, 4 months duration (16 weeks) –  Group 1 - 360 cycles at one time –  Group 2 - 90x4 cycles (3 hours between)

•  Loaded limbs (Right) - significantly greater bone density •  Group 2 - significantly greater bone density •  Conclusion: Shorter duration with periods of rest may be better for bone density (Robling, Hinant, Burr, & Turner, 2001)

•  8 month duration - Children with Spastic CP •  Activity Group (n=9) had significant increase in BMD (femoral neck) •  Control Group (n=9) had notable loss in BMD (femoral neck)

www.rifton.com

(Chad, Bailey, McKay, Zello, Snyder, 1999).

•  Post-Menopausal Women (n=28) •  Reciprocating Whole Body Vibration (WBV) platform compared to Walking Activity •  3x/week for 8 months •  BMD at femoral neck and balance improved with WBV - not with walking; BMD at lumbar spine did not change in either group. (Gusi, Raimundo, & Leal, 2006)

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•  •  •  •  • 

Getting in/out of standing multiple times Vibration Platforms Muscle contraction (Electrical Stimulation) Weight Shifting (functional UE activities) Standing while moving (power wheelchair)

. . . Just to name a few!

•  Ambulation/Ambulatory Aids – Quality of weight bearing? – Upper extremity support required?

•  Separate Standing Devices – Static or Dynamic

•  Wheelchair Standing Devices – Manual/Manual – Manual/Power – Power/Power

• Bionic Exoskeleton

•  Tilt table stand (lay-to-stand) •  Semi-reclined stand (“loose” sitto-stand) •  Tight sit-to-stand •  And anything in between!

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Wheelchair Standers

•  Improve compliance with standing program (Shields 2005)

•  Promote functional independence –  Reduces cost of home modifications •  Enhance medical benefits of weight bearing –  Higher Frequency (Robling 2001; Eng 2001) –  Dynamic Loading (Thompson et al 2000; Ward et al 2004) •  Provide superior and functional means of pressure relief (Sprigle 2010) –  Reducing risk of pressure ulcers –  Helps heal/treat current pressure ulcers

•  How often are individuals participating in a supported standing program? –  Survey studies –  Case studies –  Clinical experience

http://caribbeanweightwatchers.files.wordpress.com/ 2011/05/treadmill-with-clothers-on-it.jpg

Dunn et al. (1998) •  National survey study of individuals with a SCI who had a separate standing device (n=99; 32% response rate) •  77% paraplegia •  84% reported using their standing device –  41% reported using it 1-6x a week –  67% stood for 30min-1hour each time

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Eng, Levens, Townson, Mah-Jones, & Bremner (2001) •  Surveyed the use of separate standing devices in individuals with SCI. n=126 •  30% stood on average 40min/session, 3-4x week •  Most common reason for not participating in a standing program – cost of device

•  Single Case – 25yo man with T10 complete paraplegia. Standing Wheelchair monitored x 2 years •  Exceeded recommended minimum dosage (130.4%) •  Short duration (Mean = 11.57 minutes) •  Average 3.86 days/week •  Reported improved spasticity and bowel motility (Shields & Dudley-Javoroski, 2005)

•  Dunn et al. (1998): Respondents reported improved bladder emptying, bowel regularity, decreased UTIs, leg spasticity, and less “bed sores”. 78% “highly recommend” the use of the standing device •  Survey by Walter, et al. (1999). Found improvements in QOL, fewer bed sores, fewer UTIs, improved bowel regularity, improved LE ROM. Benefits were seen even if standing began several years after injury •  Survey by Eng et al. (2001) perceived benefits included improved well-being, circulation, skin integrity, bowel/ bladder function, digestion, sleep, pain, and fatigue.

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•  6 paralyzed men from VA (average 19 years in w/c) •  Use of static standing frame •  Avg. Standing time - 144 hours over a mean of 135 days •  No significant improvements in ROM, Spasticity or Bone Density •  Positive psychological impact noted and men continued to uses standing frame because it made them “feel” healthier. (Kunkel et al., 1993)

•  Gain medical benefits of weight bearing in upright position •  Perform functional activities in standing position •  More natural position (esp. pressure redistribution) •  Reduce amount of caregiver assistance required –  Often paid attendants

•  Improved compliance with standing program •  Provide energy conservation –  Less transfers required

•  Psycho-social benefits •  Supports clients self-chosen desire to stand –  Improved autonomy

•  Improves  ver,cal  range  of  reach   –  Kitchen  counters/cabinets,  medicine  cabinets,   refrigerator,  sinks,  drawers,  closets,  thermostat,  light   switches,  window  shades/blinds,  etc.)  

•  Improves  produc,vity  at  work  or  school   •  Improves  psychological  well  being   •  Improves  performance  of  MRADLs  (ADLs/IADLs)   –  Toile,ng,  Feeding  (cooking),  Dressing  (access  to   closets/drawers),  Grooming  (access  to  mirrors/sinks),   Bathing  (access  to  supplies)  

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•  Improves compliance with standing program (Shields, 2005)

•  Promotes func,onal independence •  Greater  medical benefits of weight bearing (Robling, 2001; Eng, 2001)

– Higher Frequency – Dynamic Loading •  Provides natural means of pressure  relief   (Sprigle, 2010)

– Reducing risk of pressure ulcers – Helps heal/treat current pressure ulcers

•  Funding Challenges •  Positioning Challenges –  Sitting and Standing

•  Bone Density Requirements –  Safety

•  Complexity of Equipment •  Range of Motion Requirements

•  Standing sequence used and set up of equipment is CRITICAL to manage positioning. •  Advanced programming and shearreducing (sliding) backrest also help control for shifting in seating system. •  Contractures (if not severe) CAN be accommodated in the standing wheelchair if providing programmable electronics.

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•  Fractures typically happen with abnormal force –  Not usually in controlled standing situation

•  Use tilt table to determine standing tolerance and progression –  Obtain physician clearance

•  Lay to Stand sequence (power standing) will minimize risk more than Tight sit-tostand.

Problem:     Funding  for  wheelchairs  con5nues  to  diminish  =   People  are  not  ge9ng  wheelchairs  that  work  best  in   their  lives.   Why?:    

•  Insurance  en55es  do  not  value  wheels.   (deny,  deny,  deny  –  coun5ng  on  us  giving  up)  

•  No  fancy  and  expensive  lobbyist  for  wheelchairs   •  Un5l  now,  no  disability  orgs  concentra5ng  on   complex  rehab  technology.  

Solu5on:   Con5nue  to  develop  and  sustain  an   educated  grassroots  network  of   consumers,  family,  advocates,  and   healthcare  professionals.  

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•  Wheelchairs  are  NOT  expensive.     •  Medica5ons  are  far  more  expensive   per  year  than  mobility  equipment  

What  you  can  do   1.  Register  everyone  at  www.usersfirst.org  “Join   with  us”  buUon   2.  “like”  UsersFirst  on  Facebook       www.facebook.com/UsersFirstAlliance   3.  Use  the  Mobile  Registra5on  Form  “Save  the   Wheelchair”  buUon  on  website.    

he We can

lp!

Website: www.permobilus.com/funding/php LMN Generator: www.permobilLMN.com Email: [email protected]

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Questions?? www.permobil.com

•  Alekna, V., Tamulaitiene, M., Sinevicius, T., & Juocevicius, A. (2008). Effect of weight-bearing activities on bone mineral density in spinal cord injured patients during the period for the first two years. Spinal Cord, 727-732. •  Adriaansen, J., van Asbeck, F., Lindeman, E. v., de Groot, S., & Post, M. (2013). Secondary health conditions in persons with spinal cord injury for at least 10 years: design of a comprehensive long-term cross-sectional study. Perspectives in Rehabilitation: Developing Robust Research Designs, 1104-1109. •  Arva, J., Paleg, G., Lange, M., Liberman, J., Schmeler, M., Dicianno, B., et al. (2009). RESNA Position on the Application of Wheelchair Standing Devices. Assistive Technology, 161-168. •  Baker, K., Cassidy, E., & Rone-Adams, S. (2007). Therapeutic standing for people with multiple sclerosis. International Journal of Therapy and Rehabilitation, 104-109. •  Bohannon, R. (1993). Tilt table standing for reducing spasticity after spinal cord injury. Archives of Physical Medicine & Rehabilitation, 1121-2.

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•  Caulton, J., Ward, K., Alsop, C., Dunn, G., Adams, J., & Mughal, M. (2004). A randomized controlled trial of standing program on bone mineral density in non-ambulant children with cerebral palsy. Archives of Disease in Childhood, 131-135. •  Chad, K., Bailey, D., McKay, H., Zello, G., & Snyder, R. (1999). The effect of a weight-bearing physical activity program on bone mineral content and estimated volumetric density in children with spastic cerebral palsy. Journal of Pediatrics, 115-117. •  Chang, A., Boots, R., Hodges, P., Thomas, P., & Paratz, J. (2004). Standing with the assistance of a tilt table improves minute ventilation in chronic critically ill patients. Archives of physical medicine and rehabilitation, 1972-1976. •  Dalyan, M., Sherman, A., & Cardenas, D. (1998). Factors associated with contractures in acute spinal cord injury. Spinal Cord, 405-408. •  Deitrick, J., Whedon, G., & Shorr, E. (1948). Effects of immobilization upon various metabolic and physiologic functions of normal men. American Journal of Medicine, 4(3).

•  Dudley-Javorski, S., & Shields, R. (2008). Muscle and bone plasticity after spinal cord injury: Review of adaptations to disuse and to electrical muscle stimulation. J Rehabil Res Dev., 45(2), 283-296. •  Dudley-Javorski, S., & Shields, R. (2012). Regional cortial and trabecular bone loss after spinal cord injury. Journal of Rehabil Res Dev., 49(9), 1365-1376. •  Dunn, R., Walter, J., Lucero, Y., Weaver, F., Langbein, E., Fehr, L., et al. (1998). Follow-up assessment of standing mobility device users. . Assist Technol, 84-93. •  Edlich, R., Winters, K., Woodard, C., Buschbacher, R., Long, W., Gebhart, J., et al. (2004). Pressure ulcer prevention. Journal of Long Term Effects of Medical Implants, 285-304.

•  Edwards, L., & Layne, C. (2007). Effect of dynamic weight bearing on neuromuscular activation after spinal cord injury. American journal of physical medicine and rehabilitation, 499-506. •  Eng, J., Levens, S., Townson, A., Mah-Jones, D., Bremner, J., & G., H. (2001). Use of prolonged standing for individuals with spinal cord injuries. Phys Ther., 1392-1399. •  Glickman, L., Geigle, P., & Paleg, G. (2010). 2010. A systematic review of supported standing programs. Pediatric Physical Therapy, 197-213. •  Goemaere, S., Van Laere, M., De Neve, P., & Kaufman, J. (1994). Bone Mineral Status in Paraplegic Patients who Do or Do Not Perform Standing. Osteoporosis Int, 138-143. •  Gudjonsdottir, B., & Mercer, V. (2002). Effects of a dynamic versus a static prone stander on bone mineral density and behavior in four children with severe cerebral palsy. Pediatric Physical Therapy, 38-46.

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•  Gusi, N., Raimundo, A., & Leal, A. (2006). Low Frequency vibratory exercise reduces the risk of bone fracture more than walking: A randomized controlled trial. BMC Musculoskeletal Disorders, 7(92). •  Hoening, H., Murphy, T., Galbraith, J., & Zolkewitz, M. (2001). Case Study to Evaluate a Standing Table for Managing Constipation. SCI Nursing, 74-77. •  Kaplan, P., W., R., Gilbert, E., Richards, L., & Goldschmidt, J. (1981). Reduction of hypercalciuria in tetraplegia after weightbearing and strengthening activities. Paraplegia, 289-293. •  Kunkel, C., Scremin, A., Eisenberg, B., Garcia, J., Roberts, S., & Martinez, S. (1993). Effect of "standing" on spasticity, contracture, and ostoporosis in paralyzed males. Archives of Physical Medical Rehabiliation, 73-78. •  Paleg, G., Smith, B., & Glickman, L. (2013). Systematic Review and Evidence-Based Clinical Recommendations for Dosing of Pediatric Supported Standing Programs. Pediatric Physical Therapy , 25, 232-247.

•  •  •  •  •  •  • 

Rubin, C., Sommerfeldt, D., Judex, S., & Qin, Y. (2001). Inhibition of osteopenia by low magnitude, high frequency mechanical stimuli. DDT, 848-858. Robling, A., Hinant, F., Burr, D., & Turner, C. (2002). Shorter, more frequent mechanica loading sessions enhance bone mass. Medicine and science in sports and exercise., 196-202. Shields, R., & Dudley-Jaroroski, S. (2005). Monitoring standing wheelchair use after spinal cord injury: a case report. Disability & Rehabilitation, 142-146. Sonenblum, S.E. & Sprigle, S. (2011). Distinct tilting behaviors with power tilt-in-space systems. Disability and Rehabilitation: Assistive Technology, 6(6), 526-35. Sprigle, S., Maurer, C., & Sorenblum, S. (2010). Load Redistribution in Variable Position Wheelchairs in People with Spinal Cord Injury. Journal of Spinal Cord Medicine, 58-64. Tsai, K.-H., Yeh, C.-Y., Chang, H.-Y., & Chen, J.-J. (2001). Effects of a Single Session of Prolonged Muscle Stretch on Spastic Muscle of Stroke Patients. Proc. Natl. Sci. Couc., 76-81. Walter, J., Sola, P., Sacks, J., Lucero, Y. L., & Weaver, F. (1999). Indications for a home standing program for individuals with spinal cord injury. Journal of Spinal Cord Medicine, 152-158.

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