Standing for Life Helping patients with paralysis to stand as soon as medically stable is critical to their improvement. Physical therapists are frequently unsure how best to help patients with neurological injuries (e.g., multiple sclerosis) that result in paralysis. These patients are often confined to beds or wheelchairs for hours at a time, ending up with unwelcome physical, physiological and psychological changes, such as pressure sores, joint contractures, osteoporosis, lung and kidney infections and depression. One method of physical therapy, often overlooked with these patients, is standing. In the opinion of many physicians and therapists, it is crucial that patients with paralysis be helped to stand as soon as medically stable following the illness or injury. They should stand every day for gradually increased lengths of time. Benefits of Passive Standing The reasons why paralyzed patients must stand are too numerous to mention. Among the most important are the prevention of contractures, improved range of motion, reduction of muscle spasticity, prevention of osteoporosis, improved circulation, reduction of lower extremity edema, pressure relief to vulnerable areas to help prevent pressure sores, improved bowel and bladder regularity, fewer kidney stones and decreased risk of chest infections and pneumonia. Even patients who are comatose who are helped to stand have shown improved motor response, and possibly shortened periods of unconsciousness. There are three kinds of adaptive equipment that help patients stand. Tilt tables These are portable mat tables on which a patient lies supine with straps across the knees, hips and chest to hold the body in place. The therapist gradually brings the patient to an almost vertical position by inclining the table mechanically. Most often used in hospitals during the acute phase of rehabilitation, the tilt table is beneficial for patients with SCI, especially those with high-level quadriplegia, and may also be used with unconscious patients, as well as patients who have developed lower extremity contractures. Some disadvantages are that they can cause patients with severe TBI to exhibit an increase in plantar muscle tone (positive supporting reaction), because the sensation of going from supine to standing is not a normal movement pattern and patients may become anxious or agitated. Also, the tilt table takes up a lot of space, so is often impractical for home use. Standing frame/tables The patient stands from a sitting position and is supported in a fully upright position by a solid frame with a padded strut in front of the knees to keep them extended, and a belt and gate behind the hips to prevent them from flexing. These frames are mostly stationary, but there are frames the patient may "drive" while standing. Since it allows for a more normal movement pattern (sit-to-stand), the standing frame helps facilitate increased motor control in trunk and leg muscles. Patients can also perform tasks at the table (e.g., playing cards, knitting, reading), which would be impossible using a tilt table. Disadvantages include difficulty to stand a patient who is unconscious or who has high-level quadriplegia, because getting the patient into the frame is awkward and potentially dangerous. If the patient has significant lower extremity joint contractures, he would be unable to stand in the frame because the biomechanical alignment of the lower extremities would not permit the safety gate to lock in position. The patient would also experience pain in this vertical alignment. These are also cumbersome for use at home and in the community. Standing wheelchairs. These may be either power or manually operated, and are used both to achieve regular mobility and to stand the person up independently with hydraulics or power. Some standing wheelchairs may be driven from the standing position; however, some feel there is an increased risk of long bone fractures while driving in a standing position (with legs under load) and caution against this. This device is the most functional and mobile of the three, and is ideal for the alert, oriented person who can do functional things while standing (e.g., shopping, cooking). Also, these are ideal for standing patients with joint contractures, since the vertical height at which the patient can comfortably stand can be controlled by limiting how high the wheelchair will raise. Hence, the patient may partially stand until the muscles elongate enough to allow increased range of motion. These can be easily used in the community. One disadvantage is that standing wheelchairs are expensive. Some companies help families get the chair covered by insurance. Evaluate, Establish Goals Before deciding which device to use for a particular patient, the therapist must complete a thorough evaluation and establish individual goals. Determining the severity of the patent's disability, both physical and cognitive, will help the therapist select the most appropriate standing equipment. I have worked with several patients using standing as an integral part of their therapy. In most cases, I opted for the standing wheelchair for reasons outlined above. Case History #1 In 1992, 25-year-old "Joe" suffered severe traumatic brain injury from an auto accident. Because of prolonged sitting and general inactivity, Joe developed bilateral ankle and knee contractures. In 1995, bilateral gastrocnemius and hamstring releases were performed to lengthen his muscles, but were relatively ineffective. I began working with Joe in January 2000 at the Eisenhower Center, a post-acute live-in rehab facility in Ann Arbor, MI. At this time, his knee contractures were 40 degrees bilaterally. I knew Joe needed to stand to strengthen his legs and improve his health, but when we tried to put him on a tilt table, he became agitated. The severity of his contractures made it difficult for him to stand straight enough to use a standing frame. In June 2000, Joe was given Botox injections to get his hamstrings to decrease spasticity, along with serial casting. The goal of these treatments was to lengthen his hamstrings and gain more knee extension, but the treatments added to Joe's anxiety and agitation, and hence were discontinued. He now had approximately 30-degree knee contractures bilaterally. We continued with daily range of motion exercises, but the contractures gradually worsened and Joe was again at 40 degrees bilaterally. I knew Joe would need a standing wheelchair if he was going to make the progress we hoped for, since it is the only standing device that let a patient stand with bent knees (with contractures). I learned that we could put a chain link as a limit on the chair to make it impossible for Joe to take the chair higher than his bent knees could tolerate. As his contractures lessened, we would add links in the chain to allow him to go higher. I also suspected the natural sitting-to-standing pattern would be more comfortable for Joe, and that he would not become agitated and would feel more in control, since he would be able to operate the standing and sitting mechanics of the wheelchair by himself. In March 2001, Joe was re-evaluated for a standing wheelchair. We received a doctor's prescription. A letter of medical necessity was forwarded to Joe's insurance company, and he received his standing wheelchair in June 2001. Joe began to stand daily in physical therapy for frequent short intervals. Intermittent frequent standing lengthened Joe's hamstrings, and by January 2002, his bilateral knee contractures had improved to 20 degrees. Joe now stands regularly throughout the day up to an hour at a time with his caregivers. Case History #2 Fifty-six-year-old "Harry" sustained a spinal cord injury at level C5/6 in July 2002 following a car accident. His initial rehab at the University of Michigan hospital focused on upper extremity strengthening and range of motion exercises, but he didn't have an opportunity to stand passively during his inpatient stay. In October 2002, Harry was transferred to the Eisenhower Center, where I began working with him. Harry really wanted to stand again. At first, we stood him with a tilt table, but in closely monitoring his blood pressure, we noticed that he became severely orthostatic hypotensive(50/40) at around 65 degrees vertical. Tilt tables, with their rather drastic change from lying to standing, often cause this problem. The physiatrist recommended that Harry wear an abdominal binder and lower extremity compression (full leg) stockings. We were able to gradually elevate him from supine to standing in 5-degree increments. Although Harry was benefitting physiologically from the tilt table, the method itself was extremely time consuming, since it involved two transfers: first, from bed or wheelchair to elevating mat table; then, from mat table to tilt table. Also, two people were needed for this double transfer. This process limited the time we had to work toward our other important physical therapy goals (i.e., transfers, sitting balance, bed mobility, upper extremity strengthening). Because the tilt table takes the patient from lying to standing, without sitting in between, great care must be taken. Before standing, the patient's supine blood pressure must be greater or equal to 90/70. If it drops below 80/60 while standing, he must be returned to supine. If there is any lightheadedness or tingling in the ears, he must be lowered again. So in December 2002, I arranged for Harry to try some standing wheelchairs. I immediately noticed that his blood pressure remained more therapeutic and stable (greater or equal to 80/60, in full vertical position), because of the more natural elevation of sitting to standing pattern, as opposed to the extremes of supine to standing. After these trials, I contacted Harry's physiatrist and recommended that he be given his own standing wheelchair. The doctor said that before he would agree to write the prescription, he wanted to see more long-term benefits of a standing wheelchair, especially with regard to regulating Harry's blood pressure. I again contacted the companies. Although, they don't typically provide loaner or rental standing wheelchairs, one company made an exception. Harry's auto insurance company negotiated on a rental price with the option to buy. Harry received his rental standing wheelchair in March 2003. At first, Harry stood only in his physical therapy sessions, so we could closely monitor his blood pressure. Frequent, short periods of standing helped increase his blood pressure, but at first, standing for more than three minutes at a time led to orthostatic hypotension. Harry was independent in operating the power controls to drive and stand/sit. Once his standing blood pressure stabilized, Harry began to use his wheelchair throughout the day to relieve pressure and perform functional tasks. Most gratifying, he could use the wheelchair in the community for banking, shopping and other errands independently. In July 2003, I updated the physiatrist on Harry's progress with the standing wheelchair. His doctor was pleased and agreed to write the prescription, and the insurance company has approved payment for the rental chair to be purchased. Standing is crucial for every patient, including those with paralysis, for physical and psychological health, and to prevent serious, life-threatening medical complications. Physical therapists nationwide should always consider adding standing to the treatment plans of patients with paralysis. The fact that insurance often pays for this under-utilized option should be a plus. Marjorie D'Alecy graduated as a physiotherapist from The Queens College of Glasgow, Scotland in 1992. She worked at the Scottish Neurological Institute and Spinal Cord Injuries Rehab unit at the Southern General Hospital, Glasgow until moving to Michigan in 1994. She has been working at the Eisenhower Center, a Neurological Rehabilitation Center, since 1997. She can be reached at 734-677-0070, ext. 320.