Clinical Case Studies

To Stand or Not to Stand
By Kirsten Becker, PT

The correct stander can improve a patient’s physical and psychological well-being.The use of standing aids has widely increased over the last 10 years. Several manufacturers have created mechanical and motorized methods of raising people from a sitting to a standing position. However, the basic positioning device remains the same. The three main devices include prone, supine, and vertical or upright standers.

The prone stander supports the front of the body and is used for people with good head control by enabling weight bearing through the arms. This type of stander promotes use of extensor muscles to remain upright and thus promote head elevation. The second type is the supine stander. It supports the person along the back of the body and has several adaptations to facilitate improved function. Most of these standers have trays or are placed against a table to provide a work space. The third type is the vertical or upright stander. It is used to gain maximal weight bearing through the body as it mostly consists of support around the trunk using a table or box.

These standers are usually inexpensive and are used with people who have better balance and trunk control. They can be fabricated by anything the client can lean against or stand inside. In addition, there are mobile standers that allow the clients to self-propel themselves around their environment, stand-up wheelchairs to move from sitting to standing, sit to stand standers, and glider standers. Beyond the basic types of standers, there are many variations and modifications designed to fit and support all types of people.^1,2

STANDERS IN THE CLASSROOM
There are many benefits of standing for all clients, particularly those who are wheelchair-bound. These people are limited in their ability and are at high risk for many medical conditions due to the amount of sitting performed during their day.

In the school setting, wheelchair-bound children are not at the same height as their peers, which can have a negative psychological effect on them. While in a stander, a nonambulatory person will be much taller and can improve their social interactions and their self-esteem. The stander with a tray can be used to eat lunch, work on class projects, and play games and can support improved upper body function and control. The stander without a tray can be used to work on ball skills—throwing and catching—groom hair, brush teeth, and perform other daily living activities.

While in the stander, the student can function like their ambulatory peers while performing these activities. In addition to the above psychological and functional benefits, standing provides several physiological and medical benefits. Benefits include: improved digestion, improved muscle activity, decreased muscle contractures, improved bone density, decreased risk of fractures, improved bladder drainage and kidney function, improved circulatory and cardiovascular systems, and improved skin integrity through relief of pressure sores caused by prolonged sitting. The human body was designed to weight bear on two limbs, and thus most of our internal organ function is enhanced through standing.²

Standers can be used during several settings within the school day and are meant to be integrated into the classroom with the students’ peers. These standers should not isolate the child, but bring them to the level of their peers and improve peer and social interaction.

ROLE OF THE THERAPIST
The therapist in any setting needs to consult with the entire team to obtain the appropriate standing device. This team may include the school case manager, parents/caregiver, group home, physician, vendor, therapists, and anyone else involved in assessing the standing need.

The team needs to assess the indications and contraindications to standing. These clinical indications include risk for any immobilization dysfunctions including paralysis, prolonged sitting, and impaired mobilization. Clinical contraindications include physician-declined referral, orthostatic intolerance, and impaired skeletal structure that will not tolerate weight bearing. These syndromes could include diagnoses such as orthostatic hypotension, postural tachycardia syndrome, osteogenesis imperfecta, osteoporosis, and other brittle bone diseases, as well as hip or knee flexion contractures greater than 20°.¹

Clients need to obtain proper alignment with necessary braces to promote increased function and interaction. Teams need to think about the appropriate stander in relation to the number of staff needed to obtain the proper standing posture, as well as designing an appropriate standing program. Therapists need to assess the frequency of and compliance with the standing program to obtain optimum functional performance within the school and home settings. To obtain the proper stander, therapists have to communicate this need via documentation with insurance companies.

STANDER JUSTIFICATION
After we know the benefits of standing, how do we convey this information to insurance companies and justify payment for this equipment? This can be one of the most difficult things for a therapist to document.

As clinicians write more and more justifications for standers, reimbursement has improved. Insurance companies are realizing it is often cheaper to buy a piece of equipment, rather than risk surgery, postural abnormalities, or other physiological dysfunctions.

After you determine the need for the stander, the evaluation begins to determine which stander will maximally benefit the client. We need to assess the diagnosis, range of motion, tone, sensation, skin integrity, functional status, and living and school environments. Is the client going to use the stander only at school or only at home? How accessible and feasible is the classroom or home for standing with this equipment? We also need to consider the age and size of the person. Are they going to outgrow this stander or have difficulty transferring into the stander? Often as the child grows larger, transfers into the stander become more difficult. We need to account for these factors during the evaluation.³

Other information that needs to be gathered includes documenting how long and often the stander will be used, medical necessity, and home compliance. Determining the kind of stander needed is also important to rule out other types of equipment. It is sometimes necessary to discuss and perform a trial of several types of standers to enable appropriate fit and ease of standing. It is always necessary to document these trials, as well as to justify why this stander is the most effective for the client and to rule out the lesser priced models. It is also necessary to determine if the funding source has a dollar limit. These factors need to be documented to support justification of any type of stander.

Despite our best efforts, we can get our equipment denied even if we deem it medically necessary. If, after appeals, phone calls, letters, etc, we still have not received insurance authorization, keep in mind that other local organizations are often willing to assist in purchase of medical equipment. These could include adult civic groups, such as Lions Clubs; the Knights of Columbus or similar church groups; diagnosis-specific organizations; or school systems. Loaner programs also exist via schools or Goodwill organizations that receive donated equipment, loaning it to families for short durations.

When looking to obtain a stander for a person of any age, consider all of the benefits—medical and psychological—and, finally, document all of these criteria for justification to the insurance company.

Kirsten Becker, PT, is a therapist at Spot Rehab, St Cloud, Minn.

REFERENCES

1. Wankelman P. Standing 101. SMART Educational Seminars. February 2, 2004.
2. ABLEDATA Fact Sheet Number 28, June 1999. Available at: www.abledata.com. Accessed January 12, 2005.
3. Koch KE. Taking a stand. Rehab Management. 2002;15(6):20-21.

1. Altimate Medical. Available at: www.easystand.com. Accessed January 12, 2005.
2. Krump PJ. Taking a stand. Advance for Directors in Rehabilitation. March 2000.