Stand Up!

The benefits of standers for children are clear

by Kathy Wechsler on January 1, 2009 - 2:31pm

QUEST Vol. 16, No. 1

Ten-year-old Morgan Fritz of St. Peters, Mo., received a spinal muscular atrophy (SMA) diagnosis when she was 15 months old. Three months later, she began a standing program, and she’s kept at it ever since.

Instead of a wheelchair, Morgan, who was the 2005 MDA National Goodwill Ambassador, uses a Standing Dani Dynamic wheel stand from DavisMade as her main form of mobility. She typically stands for four to five hours per day, as recommended by her physical therapist (PT).

Although there’s no scientific proof, her parents, Ron and Sue Fritz, believe Morgan’s standing routine over the years is a big reason why she doesn’t show any signs of scoliosis (curvature of the spine) today.

Whether or not standers actually slow the development of scoliosis, the devices do provide a host of other benefits for children with neuromuscular diseases.

Morgan’s Standing Dani helps her groom her horse, Mouse.

Children who aren’t walking, or who have mostly lost their ability to walk, should start a standing program sooner rather than later, experts recommend.

But standing is not as simple as it sounds. There are a variety of things parents should consider when deciding on the right stander for their child.

When to stand?

There’s no set age for when children should start standing, says Mary Fournier, a PT who works with the MDA Clinic at Rhode Island Hospital in Providence. She also is the clinical supervisor for the hospital’s early intervention program.

Standing is very individualized and depends on the diagnosis, disease onset and level of ability.

Most children who receive a neuromuscular disease diagnosis within the first few months of life can start standing at around a year, says Fournier.

Older children who have never stood, or who haven’t stood in more than five years, need a bone-density test to ensure their bones are strong enough to tolerate standing, or a bone fracture can occur, says Lauren Rosen, a PT and assistive technology practitioner (ATP) who works with the MDA Clinic at St. Joseph’s Children’s Hospital in Tampa.

If children still are walking most of the time and only using a wheelchair occasionally, they’re not yet ready for a stander, says Rosen, adding, “If I have a kid who can still move, I’m not strapping them down!”

But it’s a different story for children who are doing extremely limited amounts of walking and weight bearing, and who are sitting in a wheelchair most of the time.

“Even though they’re still able to walk — which is great, and they need to keep doing that — they also need to have some symmetrical weight-bearing therapeutic standing,” says Amy Meyer, Permobil’s pediatric and standing specialist, who is a PT and ATP.

Health benefits

The EasyStand Evolv from Altimate Medical is a sit-to-stand stander designed for teenagers and small adults.

Because the human body is designed to be vertical, its internal systems function more naturally when the person is standing. Being upright allows gravity to help empty the bladder more completely, reducing urinary tract infections. Standing also helps with digestion, elimination, respiration and circulation. Removing pressure from the rear end allows for unobstructed blood flow, helping to prevent painful pressure ulcers.

Sitting all the time puts kids at risk for developing contractures (stiffened joints and associated tissues due to weakened muscles). Supported standing straightens joints, improves range of motion and flexibility and helps to prevent ankles, knees and hips from developing contractures in a flexed position, experts say.

In addition, when children don’t bear weight on their legs, their bone density decreases, “and it decreases pretty quickly,” says Meyer. “The earlier you initiate a standing program, the less you’ve lost.”

[Note: While it’s been proved that standing helps maintain bone density, studies are inconclusive as to whether or not it improves bone density. “A lot of research is happening in that area,” says Fournier.]

Although there’s no proof that standing in a stander can prevent or slow the development of scoliosis, it does promote better posture, says Fournier.

Medical professionals have differing opinions as to how long people should stand in standers each day to get these health benefits.

Rosen, who works with both children and adults in the MDA clinic, advises standing for two hours each day.  “Not necessarily two hours at one time,” she says. “They can do 30 minutes here, 30 minutes there, but I tell them that I’d like them to shoot for two hours every day.”

Other experts say that standing for 45 minutes every day offers some benefits as well. Parents should ask their child’s PT how long their youngster should stand.

Morgan spreads out her standing time by sitting and standing throughout the day, says her mother. Her Standing Dani has a removable “bicycle-type” seat that allows her to rest from time to time.

Whatever the time frame, make sure using the stander is a positive experience for children so they want to do their standing time. Some children like to play video games, watch movies or play with toys while they stand; others like to do their homework or eat dinner while standing.

The perfect fit

Parents wouldn’t buy their children shoes that don’t fit, says Fournier. Why should buying a stander be any different? “I always recommend that a child be evaluated by a physical therapist before being placed in a stander,” she says.

Stand Aid of Iowa’s Econostand with and without the Elevated Floor.

A PT can help select the most appropriate type of stander, and the assistive technology supplier at the durable medical equipment dealer will make adjustments and order extra supports so the child is standing properly. Poorly fitting standers can cause pain, discomfort and even long-term damage, says Fournier.

Most child/youth standers adjust with the growing child and usually last at least three years. Once the child has outgrown the stander, it should be replaced for safety reasons.

Larger and taller children sometimes use adult standers. If they’re large enough but not quite tall enough for an adult model, some modifications are possible. For example, the Elevated Floor from Stand Aid of Iowa ($100) fits on any of the company’s adult standers, adding up to 4 inches of height for short adults and large children.

Types of standers

In general, standers for children come in three positions: upright or vertical (the user stands up straight), supine (the user tilts backward) and prone (user tilts forward).

Standers can be stationary (not meant to be moved while in use) or mobile/dynamic (they can be driven or propelled by the user while being used). See “Standing on the Go” for more on mobile standers.

Most stationary standers have small casters for easy transport from room to room, but it’s never advisable to move a stationary stander while the child is standing in it.

Sit-to-stand standers

A sit-to-stand stander raises the child from sitting to standing using either a manual hydraulic pump or a power lift.

Sometimes the terms “sit-to-stand” and “upright” stander are used interchangeably, because almost all upright standers have this feature, while supine and prone standers generally do not.

Sit-to-stand makes standers easier to use. Although very young children can be fairly easily put into any type of stander, it’s more difficult to position older or heavier children without this feature.

Because most sit-to-stands put the user in an upright position, they’re not appropriate for all children, warns Trent McCallson of Western Assistive Technology Consulting in Las Vegas. These standers require some trunk control and good head control, because many of them don’t provide head support.

To stand in a fully upright position, a child must have enough bone density to tolerate total weight bearing. If his or her bones aren’t strong enough, a sit-to-stand stander sometimes can be used so it’s not 100 percent raised up, and the child isn’t fully standing, says Rosen.

With some sit-to-stand standers, the child is manually transferred from the wheelchair into the seat of the stander, which then gradually stands the child while supporting the back.

Other sit-to-stands don’t require a transfer, which is helpful for parents. A child can go directly from the wheelchair to standing by having a strap placed under his or her buttocks and hooked to the stander.

The EasyStand Evolv Youth from Altimate Medical ($2,695) is designed for older children, teenagers and smaller adults under 5 feet tall. Features include a rotating seat for easier transfers and an active standing glider feature that allows the upper body to move the lower body. In addition, it offers the option of switching from a stationary to mobile stander.

Adjustable to accommodate a growing teenager, the Evolv Youth comes with a choice of a manual or power lift and can be converted into an adult stander by purchasing a growth kit ($600).

Supine and prone standers

If, for the reasons mentioned above, a child can’t tolerate being fully upright, the PT may suggest using a supine or prone stander, says McCallson. These standers offer most of the benefits of upright positioning, but the amount of weight bearing is less, depending on how much the child is tilted.

A prone stander leans children forward at varying angles, depending on their tolerance for weight bearing, and supine standers lean them backward at varying angles.

Prone standers require good head control and neck strength, while supine standers are best for children with little to no head control, says Rosen.

Because most prone and supine standers don’t have the sit-to-stand feature, children have to be lifted in manually, making them most suitable for very young or very small children.

However, Altimate Medical now offers the EasyStand Bantam ($2,095), a supine stander with a spring-assisted lift to take a child from sitting to standing. With the Bantam, the child is laterally transferred into the seat of the stander, making it easier and safer for both parent and child.

The Rifton Prone Stander (Rifton Equipment, $1,320 to $1,755), is available in three sizes for users ranging from 2-feet-1-inch to 6 feet. These standers offer manual adjustment of the angle at which the child is leaning forward, and adjustable supports for alignment of the trunk and lower extremities.

Many standers, such as Prime Engineering’s Superstand ($2,495-$3,195), offer the capability to be either prone, supine or upright. Although these frames can go fully upright, they don’t offer the sit-to-stand feature.

The Superstand can be customized for the child’s growth, and adjustments can be made without tools. It fits children from 2-feet-2-inches to 4-feet tall, and also comes in a youth model for larger children.

To learn more about standers, check out the resources in InfoQuest.

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