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Introduction

There is no doubt that over the last several years supported standing has taken center stage within the complex rehabilitation technology community.  While the usage of supported standing is not a new technology or therapeutic activity, the approval rate of supported standing by insurance entities is evolving.   As a broader population becomes aware of the benefits supported standing and considerations for supported standing within the funding world are growing, it is important to understand what the evidence has to say and how we as clinicians can utilize it to justify these pieces of equipment for our patients. Evidence based practice has been the name of the game in the occupational and physical therapy fields for many years and it certainly would play a role in justifying complex rehabilitation technology and especially supported standing.   Over the course of the last several decades researchers have looked at supported standing and its benefits to those individuals who are unable to stand on their own.  

This evidence has looked at both the prevalence of comorbidities for those in a seated position such as increased risk of urinary tract infections, reports of pain, as well as medication usage (LaBerge et al, 2021) to the ability to change one’s level of function and participation within the world in which they live and work (Kenyon et al 2021).

Over the course of this CEU article, we will discuss the current evidence by looking at the medical, functional, and participation benefits of supported standing.   While the purpose of this CEU is to review the medical and functional benefits of supported standing devices; much of the evidence that we will discuss and the benefits that we will dive into revolve around power standing mobility.   It is important to note that this evidence is not negating the importance and impact of stationary style devices, such as sit to stand and supine to stand standers, as in the case for individuals are unable to utilize power standing mobility and would still greatly benefit from supported standing.   The intention of the CEU is to not only walk through the current evidence to support the ongoing effort for power standing acceptance not only at the payor level as well as to increase the confidence of the clinicians and assistive technology providers as they approach the standing evaluation and justification process.

This evidence has looked at both the prevalence of comorbidities for those in a seated position such as increased risk of urinary tract infections, reports of pain, as well as medication usage (LaBerge et al, 2021) to the ability to change one’s level of function and participation within the world in which they live and work (Kenyon et al 2021).

Over the course of this CEU article, we will discuss the current evidence by looking at the medical, functional, and participation benefits of supported standing.   While the purpose of this CEU is to review the medical and functional benefits of supported standing devices; much of the evidence that we will discuss and the benefits that we will dive into revolve around power standing mobility.   It is important to note that this evidence is not negating the importance and impact of stationary style devices, such as sit to stand and supine to stand standers, as in the case for individuals are unable to utilize power standing mobility and would still greatly benefit from supported standing.   The intention of the CEU is to not only walk through the current evidence to support the ongoing effort for power standing acceptance not only at the payor level as well as to increase the confidence of the clinicians and assistive technology providers as they approach the standing evaluation and justification process.

Throughout the article we will touch on the following objectives:

1. Explain three medical benefits of standing.
2. Describe three functional benefits of power standing mobility.
3. Detail two realistic recommendations for standing dosage.
4. Identify two client characteristics to qualify for power standing
   mobility.

Benefits of Power Standing Mobility

Medical Benefits

There are several research supported medical benefits associated with power standing mobility; including but not limited to respiratory advantages, cardiovascular improvement and pain reduction. While all medical benefits are important, for the sake of time, we will only be covering a small sample in this CEU article.

• Bowel and bladder function
  • Our urinary and digestive systems by nature are highly dependent on gravity and our movement through it.  Evidence has shown that the introduction of dynamic movement (going from sit to stand frequently throughout the day) can assist with the movement of waste products through our urinary and digestive tracts. In both studies, done by Eng et.al., 2001 and Kwak et.al., in 2014, it was found that the implementation of frequent movement from a sitting to standing position throughout the day encouraged activation of both the urinary as well as the digestive systems.
  • Why is this important?  For those individuals who utilize wheeled mobility devices the time spent in the seated position does not facilitate urinary flow. This is even further compounded when dealing with those individuals with recent spinal cord injuries or SCIs. There is Increased risk of kidney stones due to reduced urine flow in the first three to six months post injury. The higher the level of injury the higher the chances of kidney stones and urinary tract concerns (Chen et.al., 2000).
  • Those with spinal cord injuries are not the only individuals impacted by urinary concerns related to a seated position. On the opposite end of the spectrum, the advancement in technology has allowed for greater life expectancies for those individuals who had once experienced early mortality related to their disease process or injury. Now, individuals are living 85% longer than in decades past and they are now truly aging with their disability (Molton & Yorkston, 2017). This also can be said for our elderly population who are ageing into a disability. While they may not experience neurological concerns or conditions, the decline in mobility is proving to be a challenge.  Urinary tract and digestive tract concerns such as incontinence and constipation become important considerations for those using a power mobility device power seat function (Domingos & Serras, 2011).

• Bone Mineral Density
  • The use of weight bearing has long been noted as a means of maintaining or, in some cases, improving bone mineral density in both adults and children alike. Over the last several years many studies have illustrated these results such as Damcott et.al.,2013 who found that individuals with the ability to frequently move between sitting and standing while using a dynamic standing device showed increased bone mineral density compared to those that utilized static standing devices.
  • When considering bone health and its relationship to specific diseases the following benefits can be identified
    • Duchene’s Muscular Dystrophy: Supported standing promotes maintenance of bone health in adolescent boys
    • Cerebral palsy: bone mineral density is not only maintained but, in some cases, has shown improvement in adolescents (Gannotti et.al, 2021).

• Range of Motion, Spasticity and Contractures
  • There are several additional benefits that are often overlooked in the justification of power standing mobility. In several older studies the implementation of standing allowed for improvement in both passive range of motion and active assistive through the lower extremities (more specifically the hips and ankles) in both adults and children with neuromuscular conditions.  However, the benefits of supported standing are not limited solely to the lower extremities. The upper extremity range of motion and functional reach were improved in individuals during the use of supported standing compared to traditional static seated position. (Masselink et.al, 2024, Craig et.al, 2016, Newman et.al. 2012, Paleg et.al. 2012, Gohkle et.al. 2022). 
• • Spasticity reduction has also been noted with the use of power standing mobility.  Applying weight through the lower extremities in some cases can reduce the impact and frequency of spasticity (Craig et.al. 2016, Paleg et.al. 2013).

• Pressure Reduction/Injury Management
  • As wheeled mobility and seating therapists, pressure injury and risk reduction are significant considerations when evaluating our patients. Historically we have recommended the use of tilt, recline and elevating leg rests for skin management. However, it is also important to note that power standing mobility can play an important role in reducing the risk of pressure injuries. In a study done in 2010 by Sprigle et.al, they found a greater than 75% weight reduction to the pelvis and spinous processes in standing, allowing the individual to reduce pressure to areas of high risk.
• • From a healthcare economic impact perspective, the US spends on an estimated $26.8 billion on pressure management, wound care and education.  Approximately 22.6% of patients with pressure injuries are re-hospitalized due to ongoing issues with wounds, and an average of 60,000 individuals pass away yearly from pressure related injuries (NPIAP, 2020). The question then is that if the application of supported standing can reduce weight bearing on the pelvis and spinous processes by 75%, why wouldn’t we utilize it as a strategy to promote greater pressure injury prevention?
• Pain
  • Many of our patients deal with the aspect of pain whether from the symptoms presenting from their injury, disease process, or merely prolonged positioning within their wheeled mobility system.   Pain is often the most highly reported comorbidity in those individuals using wheeled mobility and is frequently experienced throughout their day (Bayley et.al, 2020, LaBerge et.al., 2021).   In several studies looking at pain and pain management in the wheeled mobility population it was felt that the introduction of supported standing awarded the individual the ability to change position thus reducing ongoing pain in the lower extremities, feet, thoracic and lumbar spine (Bayley et.al., 2020, Dennett et.al.,2020, Hendrie et.al., 2015).

Functional Benefits

• Traditionally, our primary focus in justifying a wheeled mobility device has been focused on medical necessity.  Yet, it is important to note that payors/funding sources are starting to consider the functional benefits that power standing mobility can provide to the wheelchair user.   Power standing mobility can facilitate greater ease with mobility related activities of daily living (MRADLs) by allowing access to activities such as donning and doffing clothing, brushing one’s teeth, and application of makeup.   Additionally, power standing mobility can accelerate the return to activities required in daily life roles (mother/father, grandparent, or spouse) such as meal preparation, laundry, work and leisure. Resuming involvement in such activities within one’s home or work environment can have tremendous positive impacts.  In a study done in 2021 by Kenyon et.al, they found that there were higher levels of independence, increased ability for hand washing, reaching and independence with toileting as it came to the use of power standing mobility. Daily routines were completed faster; thus, decreasing demand for assistance and allowing more personal involvement in one’s daily care.
• Regarding functional usage of power standing devices, a survey done in 2020 of Permobil F5VS users found that individuals utilized their power standing wheelchair in shorter more frequent stints, for such activities as meal preparation, activities of daily living, chores, etc. (Permobil White Paper, 2020).

Participation

• This higher level of involvement has allowed individuals to carry over their increased functional abilities into participation. In many cases, patients reported that the use of power standing mobility would assist in their ability to return to work activities, participate in school functions, and/or extracurricular activities with the assistance of their power standing wheelchair. In recent years, several studies have begun to look at the relationship of power standing mobility to participation. One such benefit being that of improved communication. In several studies, children with cerebral palsy demonstrated improvement with standing posture, eye contact, communication, peer interactions, and vocalization (Capati et.al., 2020; Goodwin et.al., 2017; Gudjonsdottir & Mercer, 2002).

Psychosocial/Mental Functions

• Documentation and clinical justification must be medical and functional in nature; however, we also need to take into consideration what supported standing can do for an individual psychosocially. Over the last several years the focus of the evidence has been on the mental health and cognitive aspect of power standing usage. Studies have been done looking at the positive impact of mental health and self-esteem related to the utilization of power standing mobility. In many cases it was reported that people felt healthier and experienced a more positive self-image due to the use of the standing device. In a study done by Dennett et.al, in 2020 those individuals diagnosed with Multiple Sclerosis reported that they were able to increase participation in activities with the use of the power standing wheelchair thus feeling more like themselves than they had previously. In studies focusing on younger populations of individuals utilizing power standing wheelchairs report negative feelings about fitting in or standing out especially when utilizing the stand and drive features of their power wheelchair (Vorster, et.al 2019; Goodwin, 2018).
• Lower cognitive function recovery might also be possible for those adults in a vegetative or minimal consciousness state by implementing supported standing throughout their rehabilitation stay. Several studies have suggested that the lower sensory inputs that occur during supported standing and position changes when transitioning to/from standing improve, scoring on both the Mini Mental Examination but the Functional Independence Measure (FIM) (Lee et.al, 2019, Gillespie et.al., 2019).

With the multitude of medical, functional, participatory, and psychosocial benefits how do we as a complex rehab team make the correct decision in pursuing power standing mobility with our patients?  How do we know when a patient is an appropriate candidate?  When and how is it safe for my patient to stand?  When is it appropriate to pursue power standing mobility?  When should the recommendation be made – right away or several years down the road?  The questions around patient eligibility can be overwhelming and at times cause us to second guess ourselves.

Let’s start at the beginning:

• Diagnosis: Current power wheelchairs with multiple power seat functions such as supported standing are typically used with individuals with a neurological diagnosis such as Multiple Sclerosis, ALS, Spinal Muscular Atrophy, SCI, CVA etc.  Clients with these diagnoses typically will struggle with, or are, unable to complete self-supported standing activities related to a multitude of symptoms associated with their disease process or injury. Furthermore, in many cases these individuals also require the use of multiple power seat functions such as tilt, recline, elevating leg rests, and seat elevation for additional medical benefits and mobility related activities of daily living
• Evaluation
  • Range of motion and strength are considerations when the patient is utilizing the sit to stand or supine to stand features.  Many individuals with the neurological diseases or injuries listed above struggle to operate the features of stationary standing device due to range of motion and strength deficits. The use of power standing mobility allows the individual to independently change their position not only in sitting but in standing as well. 
  • Cognition: Is your client safe to operate the power standing wheelchair?  Power wheelchairs, regardless of the addition of power seat functions, are complex pieces of equipment and, at times, can become overwhelming for those with cognitive impairments. While cognitive limitations present challenges to independent use of a power chair with additional features, it is important to consider strategies for skill development and not immediately rule out this option. In some cases, you may need to work with the patient on driving skills, limit access to one or more power seat functions until they understand when and how to use these features, or adjust programming such as limiting speed, or acceleration for safety during the training period.  It is also important to determine if your patients can handle complex situations such as driving while standing and build this into the training program. The patient will also have to develop a routine (with or without assistance) to don and doff positioning accessories (chest bar, knee blocks etc.) before and after transfers.
  • Several studies have recently focused on cognitive benefits associated with the use of power standing mobility or supported standing. Schofield et.al. in 2020, found that those who were engaged in supported standing learned safe operation of their power mobility device. Older studies have noted that the use of supported standing has increased the development of planning and sequencing abilities (Flodin et.al., 2007; Nordstrom et.al., 2013; Vorster et.al., 2019).  So, while your patient might not grasp the entirety of the power standing wheelchair at first, the implication of trials and improvement in understanding and usage may be achieved through additional training (Flodin et.al., 2007; Nordstrom et.al., 2013; Vorster et.al., 2019)

• Standing tolerance: Every individual will have a different tolerance level to stand based on their previous standing history, medical or physical limitations (i.e. orthostatic hypotension, range of motion limitations) so utilizing an objective tool such as a standing trial log is a great way to help identify improvements in tolerance as well as achieve personalized goals regarding standing.   While there is not a formalized tool, some excellent measure to idenify in a log include:
  • One to two simple obtainable straight forward goals regarding standing.  This might look like improvement in time standing or degree of upright standing tolerated.
  • Transfer status in and out of the standing device as well as how much assistance is needed by caregivers or family members.
  • Time standing over the course of several days/weeks
  • Percentage of upright standing tolerated.  For example, your patient might tolerate 45 degrees of upright standing on the first day but achieve 65-70 degrees of upright standing after a few days with the device.
  • Any vital signs that you deem appropriate (BP, pulse, etc.)

The documentation of the standing trial log or something similar can be filled out by the clinician or by the patient and caregiver utilizing a static style standing frame within the clinic or within their home.    Below is an example of a standing trial log:

Prescribed Duration

Now that we have worked through the subjective and objective aspects of matching equipment to client need it is important to discuss recommendations for the duration of time spent standing.  These recommendations vary greatly depending on the client’s goals and understanding of the evidence. Systemic reviews done in 2015 by Paleg and Livingstone found the following in relation to supported standing dosage:

• For those who wish to have positive impacts on self-care, balance, ROM, cardio-respiratory, and pain should stand 30 minutes 5 times a week.
• For Impact on bone mineral density and cognitive function one should stand 60 minutes 4-6 times a week

However, this can be dialed down further regarding specific physical goals of your patient

• Lower extremity ROM: 30 minutes 3 times a week. (Baker et.al., 2007; Freeman et.al., 2019)
• Muscle tone improvement: 30 minutes 5-7 times a week. (Audu & Daly, 2015; Baker et.al., 2007; Ferrarello et.al., 2015; Krewer et.al., 2015)

One key component to determination of a supported standing routine (as in similar prescribed therapeutic exercise or activity routines) is compliance. Goodwin et.al, 2017 determined that despite the more definitive dosage recommendations mentioned above, many patients and their families failed to comply with the recommendations.  In one aspect of the study 76 % of clinicians recommended the standard 30-60 minutes of standing duration, however only 52% of their patients completed this as asked.   On the other hand, when clinicians recommended daily standing the percentage of compliance dropped to 18%.  While many of the dosage recommendations indicate longer periods of time in standing, a look back at the evidence shows that most of the benefits we receive from standing come in a dynamic fashion.  Frequent bouts of standing for shorter more functional periods of time.    Considering this, allowing the individual to stand when they want /how they want may allow for increased time in standing throughout the course of the day, making it easier for your patients to comply with your recommendations.  In simpler words…let them stand!

Matching the Patient and the Chair

Despite the long list of benefits from prescribed supported standing routines another important consideration is matching the patient with an appropriate supportive standing device.   While the focus of this article is not on static style standing devices there are times when this is indicated.  Matching the patient to either a supine-to-stand or sit-to-stand device will ensure that the device meets their medical needs and potentially increase compliance with its usage.

In a recent study in 2022, Gohlke et.al echoes the evidence found by Scherer et.al. in 2018 that matching technology to the person is important to the utilization and implementation of the device. With the increase in power standing devices becoming more prevalent in the market, how does the CRT team ensure that the patient is getting the most appropriate device. The following attributes of a power standing mobility device might ease the hesitation when selecting the most appropriate device. 

• Flexibility of set-up to allow ongoing changes
  • Customized stand sequences allow unhindered movement to and from the standing position. Not all individuals will tolerate the same stand sequence therefore, the flexibility to adjust the transition from sit-to-stand, supine-to-stand, and allowing the movement to stop anywhere in between is important for standing success.  
  • Adaptability to grow with the client as needed (width and depth)
• Positioning
  • Consider a power standing wheelchair that allows not only an optimal standing position but optimal sitting as well. Consider the seating products that the patient requires and how those products will transition from the seated to standing position based on the stand sequence selected.  This will ensure that your patient is able to maintain their optimal functional posture in both sitting and standing.
  • While standing has amazing benefits it does not negate the need for power tilt, recline, power elevating leg rests, or seat elevation.  Each of these power seat functions in their individual capacity have medical and functional benefits to the patient and therefore additional clinical justification must be provided.
• Functionality
  • While many power standing systems vary in appearance and capabilities it is important to consider the use of stand and drive. The advantages of power standing wheelchairs compared to their stationary counterparts are just that; being able to stand and drive to complete functional activities.

Conclusion

Throughout this article, we have looked at a mere snapshot of the evidence that surrounds the recommendations and applications of supported standing devices. The list of medical, functional, and psychosocial benefits continues to grow as this topic continues to be studied.  There are several additional resources available to assist your clinical partner in the justification of supported standing.  One recent resource is that of the Clinician Task Force and RESNA Position on the Application of Support Standing Devices that can be found at www.resna.org. This comprehensive scoping review takes a deep dive into the evidence of the last twenty years related to supported standing and its application to the International Classification of Function (Masselink et.al., 2024).

One component of this journey we have yet to discuss is that of advocacy for the supported standing system and the individuals that utilize this technology.  While we have seen an increasing willingness to consider and approve standing systems around the globe, we are still a long way off from full acceptance of standing as a power seat function.  In the last several years many US advocacy groups, such as ITEM Coalition, NCART, and Clinician Task Force, have combined to improve supported standing coverage for all individuals who utilize complex rehabilitation technology. As complex rehab technology suppliers and clinicians we still can assist our wheelchair users through alternative funding opportunities. The list below is a small sample of the possibilities that are available to assist individuals in not only the procurement of supported standing but for other complex rehab technologies with limited funding support.  Some of these alternative options are but are not limited to:

• Local reuse programs/ access to demo chairsFoundations (Permobil
• Foundation or diagnosis specific foundations)
• Private pay options
• Insurance additions such as HSA or FSA
• Care Credit
• Social media/ GoFundMe accounts
• Programs such as AbleNow, Help Hope Live etc.

Additional Permobil Resources

• Permobil LMN Generator www.permobillmn.com/login
• Permobil Standing White Paper 2023 Permobil White Paper: power standing update 2023
• Functional Guide to Power Standing Evidence Functional Guide to Power Standing Evidence
• US Funding Email:   US_Funding@permobil.com

Contact Ashley at ashley.detterbeck@permobil.com

Ashley Detterbeck DPT, ATP/SMS Regional Clinical Education Manager covering the Upper Midwest. Detterbeck joined Permobil in 2017 and previously ran the Wheeled Mobility Clinic at the Marshfield Clinic, Marshfield Wisconsin. Detterbeck is an active member of the Clinician Task Force where she has participated in the request for CMS coverage of standing and seat elevate and has published research on the support of power standing mobility. Detterbeck works closely with NCART to promote coverage of standing power mobility and power seat elevation coverage with the Center of Medicare and Medicaid. Detterbeck is an individual Friend of iNRRTS (IFON) and a member of the American Physical Therapy Association Neurology Section, Assistive and Technology SIG.