Some physical therapists still view standers as a way to bolster bone marrow density, but Ginny Paleg, DScPT, MPT, PT, believes those ideas should be put to rest. "Now we know that the reason [for standers] is saving the hips, saving the spine, and preserving range of motion," said Paleg, who works part time for the Montgomery County Public Schools in Rockville, Md.
The influential research that changed how many PTs view standers came from Sweden about two years ago - a relatively short period of time in a field ruled by strict evidence-based guidelines. While not quite a paradigm shift, the new way of thinking encompasses the need to not only stand longer, but in a different position.
"The legs are farther apart," said Paleg. "And it's going to require new equipment because of the way you have to position the foot to stay under the leg."
Protecting the Hips
Paleg's own recent experience working with a child with cerebral palsy bears out the efficacy of the Swedish research. "The child's hips were probably about 20% subluxed," explained Paleg, who also conducts independent consulting. "We would stand him for an hour, five days a week, in full weight bearing. We try to get the knee and hip as straight as possible. In most patients with a diagnosis of cerebral palsy - even the kids who are ambulatory - they probably need to stand. The kids who are walking need to stand three times a week for 45 minutes. The kids who are not ambulatory need to stand for 60 minutes every day."
The one hour of standing per day in non-ambulatory children essentially "protects their hips" and maintains range of motion at the hip, Paleg said. "If you look at the gross motor function measure curve, they predict at specific ages for each child when they are actually going to lose function," she continued. "And now we have evidence to suggest that that is because of range of motion, which leads to hip dislocation and scoliosis. In Sweden, they have figured out how to totally prevent contracture and decrease scoliosis by about 60%."
Manufacturers can take as much as two years to catch up to new research, and Paleg is looking forward to working with a manufacturer that launched an appropriate design about four months ago after many prototypes and field tests.
"I have been working with a company to get the right stander," she revealed. "There are only two standers on the market that give you the proper amount of adduction. A third company has one that should be out soon."
While standers frequently become a permanent fixture as a child progresses to adulthood, there are exceptions. Mary Miles, DPT, PT, a physical therapist in the Minnesota-based White Bear Lake School District, recently worked with a little boy who could not stand or bear weight at all when he was 12 to 14 months old.
Miles started him with a stander, in addition to ankle-foot braces. Within 4 to 6 weeks, he was able to stand and support his weight when Miles put him up against a couch and gently helped him stand. "In the beginning it was really maximum support [with the stander], and I could barely keep him up," she said. "He was very low muscle tone, and the stander just made a huge difference in his stability and his ability to help support his weight."
The child used the stander for about 10 months and eventually got so good at weight bearing that therapists stopped using it.
"He spent enough time standing on his own, without support at the couch, for a good 20 to 30 minutes a day," said Miles, who describes the two-and-a-half-year-old patient as hypotonic with low tone and weakness. "It's been about 16 months since I started seeing him, and he's starting to walk along furniture and starting to take some steps by himself now. The stander made a huge difference in getting him moving and stronger."
In the evidence-driven world of physical therapy, Paleg is hesitant to unequivocally declare that standers are a psychological boon to disabled children who otherwise could not stand. While she cautions that social benefits in children have not been well documented in the literature, the same is not the case for adults.
"The best place that social benefits have been documented is in adults in Sweden," said Paleg, who works in the early intervention program at her local school district. "These adults were previously functioning normally, and then they have had an accident or disease where they can no longer stand independently. They report large amounts of psychological well-being, better sleep, and a feeling of calm when using standers."
On the anecdotal side of the spectrum, Miles has seen a variety of positive interactions for children in the 10-to-12-month range who otherwise would not enjoy the "cruising" phase of walking.
"Standers can open their world to a whole different area of learning," she said. "We need to get them up in that standing position so they can be at the same height as other children, and see things at different heights. It just gives them a different point of view - and I think they feel like they're a little more a part of the group when they can be up at eye level with peers."
Even as the children improve with their new devices, Miles reports that the parents must go through their own psychological adjustment, mostly due to the sheer size of the standers. "For parents, sometimes it may be harder, because they might think initially if their child is in a stander then maybe he or she is never going to walk," she said. "It's a big change for them to deal with this big piece of equipment.
The Payment Question
As the evidence piles up for the efficacy of standers - both pediatric and adult - Paleg laments that the familiar burden of "medical necessity" can still occasionally be troublesome. Many companies still do not cover standers, and it took a well-documented lawsuit to get a major insurer to ultimately cover the devices.
In that case, insurance company bureaucrats insisted that standers were "experimental" and that evidence for their benefit was weak. "Through an industry association we were able to hire a lawyer and sue on behalf of six families, and we won five of the cases and actually got [the company] to reverse their policy," enthused Paleg. "We were able to show them that the literature had been in place for more than 40 years, and there was good Level Two evidence to support standing."
"Depending on what kind of stander you need, it can be challenging to get them approved," added Miles. "There are students who need to be in a stander that allows them to tip back in supine a little bit. With those and other kinds of standers, you have to be very specific that you've tried other things and those things have not worked. [Insurance companies] always want the least costly piece of equipment, so if you need something that has more bells and whistles you really have to justify why the child needs it so you can get that technology paid for."
Paleg agrees that PTs must continue to fight insurance company denials head-on with evidence. For Medicare beneficiaries, the scenario is a bit easier. "We really have not had a problem with Medicare paying for standers," reported Paleg. "We are starting to have them question, however, which type is best - sit-to-stand, three way - but if you can write a good letter of medical necessity, then it seems we are not having any trouble."
Greg Thompson is a freelance writer in Colorado.
In a recent blog post, Bryanne Freitag, marketing coordinator at Altimate Medical, listed 10 playful stander activities for children:
• Set up an obstacle course in the rehab gym and wheel around cones.
• Stand up to wheel through the hallways between classes in school.
• Grab snacks out of the kitchen cupboard.
• Sneak ice cream out of the freezer.
• Shoot hoops in physical education class.
• Dance, spin, and groove to your favorite music.
• Play with your friends.
• Reach your favorite board games in the hall closet.
• Bake cookies in the kitchen with a parent, grab ingredients from the shelf, then wheel to the counter top to use the mixer.
• Play tag with your family.