Many times the focus from a therapist and a family is on increasing independence and making the day easier. Both are wonderful goals which are often accomplished through positioning devices, like a special needs chair or wheelchair, and working towards greater mobility. Frequently, however, standing is pushed to the back burner over a gait trainer, whether right or wrong. But the truth of the matter is standing is important. Standing is a natural precursor to walking in a typically developing child. It is even more important to develop that skill and tolerance for upright positioning prior to beginning a mobility program. While standing before walking is a natural hierarchy, are there more benefits to be had from a standing program? The answer is an emphatic “yes!”
Why is standing so important? Before exploring all the medical reasons for the importance of standing, let’s look at the psychological aspect. Picture riding in a car or flying on a plane for a long trip, the space is tight and there is not much wiggle room, you’re just plain stuck. Now picture and remember how good it felt when you could change position, stand and stretch, and move around. Remember how your mood lifted, how the back pain started to subside and how life returned to your legs and feet. Many of the children with moderate to severe physical impairments do not have the ability to fidget in their seat for relief or stand for a stretch without help. These children are more at risk for developing contractures, chronic pain, and orthopedic impairments as a result of abnormal muscle tone if not provided with the opportunity to stretch. Now that the “it just plain feels good to change positions” defense is complete, let’s explore the medical benefits of standing.
Standing offers a wide range of medical benefits from weight bearing to increase/maintain bone strength and promote postural alignment, increase bowel and bladder function, allowing more space in the thoracic cavity for organs to expand and work, increasing circulation and respiratory functions, skin management through decreasing risk of pressure sores, muscle tone management and providing a good stretch to hip and knee flexors and heel cords which are common areas for decreased range of motion. A well designed and tolerated standing program using proper fitting adaptive equipment that is developed by a therapist with a physician’s approval is a great tool to have to assist with overall management of care. Why are these medical benefits so important in day to day life and function? Children who are at risk for osteoporosis or decreased bone mass can benefit from maintaining or increasing their bone density placing them less at risk for fractures during transfers or day to day activities. That being said, if a child has already been diagnosed with either decreased bone density or osteoporosis it is imperative to have a physician’s approval prior to beginning a home program and to be monitored closing throughout to make sure that there are not any complications.
Many children with special needs have been prescribed medications that have side-effects which interfere with bowel/bladder function and then are prescribed Miralax or another medication to assist with bowel and bladder function. A standing program is a great addition to a bowel/bladder program – it lets gravity do the work as well as allowing more space in the thoracic cavity for the organs to expand and function. Skin integrity is crucial for an individual that relies on adaptive equipment. Standing is one of the few ways to achieve almost total relief from putting pressure on prominent sitting boney prominences which is a great way for the skin to recover and stay healthy.
Muscle tone management and stretching go hand in hand. If the muscles are more relaxed with greater range of motion, it is easier to manage toileting, dressing and bathing throughout the day in addition to increased ease with transfers and positioning. If a child does not have the ability to reach the full range of motion independently, that child is at a greater risk of developing contractures. If this same child has spasticity, the risk is even greater. By placing the muscles on a stretch in standing, it causes the tight muscles to stretch and fatigue while the “weaker” muscles are given the opportunity to strengthen and contract helping to promote a better balance between the muscle groups. It is crucial that if a child has contractures or high tone, the stander is made to fit them; a full stretch may not be possible or tolerated which limits the success of the standing program. It is very important to not overstretch tight muscles as this can cause significant pain to the child, soft tissue damage and even the potential for fractures of the bones.
Standing, as mentioned, is a wonderful tool, but it has to be respected for the potential dangers and contraindications as well as the benefits. This is the reason it is imperative to have a physician’s approval and work closely with a therapist to determine the proper equipment and standing program. Hopefully, no one is running scared for the hills because we are now going to discuss the types of standers, funding, and tidbits for a successful standing program.
What are the types of standers and how do I choose the right one? As mentioned, a physician and a therapist should always be the guiding the forces when choosing a stander along with trials of the equipment. In attempts to ease into this, basic orientation will be referred to first. Orientation refers to starting position when placing a child in a stander: prone – stomach first, supine – back first, sit-to-stand – sitting position first. Beyond these classifications are combination standers which can be set up for more than one position (i.e. supine or prone), dynamic standers (the stander base is on wheels and mobile), and vertical standers (standers are fully upright against gravity).
Let’s start by exploring the hierarchy from most supportive to least supportive. The most supportive standers are the supine standers. These standers offer the most assistance and positioning support for helping against gravity. These standers work best for those that may not tolerate full weight bearing, have limited to infrequent head control, decreased tolerance for full upright positioning, and weaker trunks. Examples of the supine standers include the Superstand by Prime Engineering and the Leckey Horizon by Leckey. Next in line, are the prone standers. Prone standers still provide significant positioning assistance and postural supports and generally require more head control than the supine standers. These standers are great for children who can use extensor tone and/or push through their arms onto a tray for upright trunk posture. It helps to further strengthen the muscles for against gravity positioning. Many times chin prompts are available as an accessory to assist with fatigue if needed. Examples of prone standers are the Leckey Freestander and Rifton Prone Stander. Lastly, there are the sit-to-stand standers that offer the ability to weight bear along any point from a sit to a stand. These standers typically require better trunk control and head control than the prone and supine, although, trunk supports are available. Many times, these standers are able to accommodate knee contractures since one is able to stop at any point during the standing process. Examples of sit-to-stand standers include, the Easy Stand Bantum and the Easy Stand Evolv. Just to reiterate, it is imperative not to over stretch or put too much pressure on overly tight muscles and restricted joints; doing so may cause severe injury or damage to joint/bone and muscle integrity.
Within these categories, there are the subcategories of combination, dynamic and vertical standers. A combination stander implies that it can do more than one thing. For example, it may be able to be used both in supine and prone with a conversion kit. A dynamic stander incorporates some type of movement. It may be on a mobile base so that the stander can be moved throughout the environment, which is a great feature to have for storage and to make the stander more versatile. The stander may also have large wheels that allow the child to propel the stander throughout the room for independent mobility even while standing. This is a great option for a child that is an independent wheelchair propeller but still needs to stand. The vertical stander positions the child in a full upright position with all gravitational forces acting on the child. For this position, a child needs to be able to tolerate standing upright with full weight bearing through the legs and hips. Many standers can be adjusted up to a full vertical position.
Next, let’s talk about funding. If a child will need both a stander and a gait trainer, always submit for the stander first. This follows the proper continuum of progression both developmentally and from an equipment standpoint. If the gait trainer is submitted for insurance funding first before the stander, the stander has a greater chance of being denied since insurance will question the need for a stander if the child is able to use a gait trainer. It may be deemed duplicate equipment or viewed as unnecessary since a child can stand in the gait trainer; unless there has been a documented decline in function (i.e. muscular dystrophy). If this has happened and a stander is still needed, there are many options to explore for alternative funding. There are waiver programs, community funding sources, local churches and organizations that may be able to help off-set the cost.
Finally, where do we start once we have a stander? It is important to make standing fun and not a chore or it will be resisted. Remember it is something new to the child and scary. The muscles take time to get acclimated to standing; so start in small increments of time (5-10 minutes) and gradually build up to an hour at least once a day or as recommended by the child’s therapist and physician. Be sure to plan favorite activities around standing to make it more fun and tolerable for the child. Let the child watch a video or listen to a favorite song. If the child has a dynamic or mobile stander, dance to the music, go “trick-or-treating” in the neighborhood or inside, plan a cooking activity, use the stander and have a child help decorate the Christmas tree or use a simple switch activity to keep the child engaged. When making things fun for a child, we are only limited by our creativity.
If at any time, it becomes too confusing or difficult to navigate through the world of standers or any other piece of equipment, please do not hesitate to contact us here at Tadpole Adaptive. We are always willing to provide unbiased and informed guidance.