Daniel is now an 8-year-old. He likes video games, skiing and playing other sports. The only difference between Daniel and most other kids is that he was born with an avulsion of his spinal cord from C5 to T1 that resulted in complete quadriplegia.
Daniel is fortunate to have great parents who accepted his disability and who have never let it define him or their lives. Part of this acceptance was getting him the proper adaptive equipment early and changing the equipment as he has grown. His parents have always been open to exploring any equipment that would benefit him.
Daniel had his first sit-to-stand stander before he was 1. He used it regularly and had very few problems as a result. His spasticity decreased on days when he stood, he had very few urinary tract infections (which are common in people who catheterize), and his passive range of motion was always good. That stander was increased to a larger size as he grew.
Along the way, he's also had a medical stroller, two power wheelchairs (one he started using at 11 months of age), and a titanium manual wheelchair. He uses the manual wheelchair for limited distances and when he goes to sports camp.
Living in Colorado with so many hills and regular snow, with his injury level and his young age, manual wheelchair propulsion is not functional and cannot provide him with enough regular and effective cardiovascular exercise. As he gets older, the hope is that he will have the upper-extremity strength and endurance to use a manual wheelchair more regularly.
When Daniel outgrew his last stander, the decision was made to try a glider stander so he could regularly get cardiovascular exercise and strengthen his upper extremities while getting all the benefits of dynamic standing. This would help him accomplish his goals of being able to propel a manual wheelchair more frequently and more independently.
He did a trial with the stander and he and his family loved it. They liked that the operation was similar to his previous sit-to-stand standers, and the fact that he could improve his upper-extremity strength while getting dynamic weight bearing through his lower extremities. So the process of obtaining the stander began.
Daniel received his most recent power wheelchair about a year before he needed the new stander. At that time, his funding source denied a standing power wheelchair so everyone was unsure whether they would fund a glider stander. Focusing his letter of medical necessity (LOMN) on the specific benefits of a glider stander versus the benefits of a static stander was the only way to get the stander.
Equipment Justification
The standard LOMN for a stander focuses on range of motion, decrease of spasticity, and basic information about bone density.
When asking for a glider, the letter had to focus on the additional benefits of dynamic standing and why this would make a difference for Daniel. Many payer sources would consider the glider feature as simply an exercise device, and would not fund it if it was not properly justified.
As with many children with spinal cord injuries, Daniel is at increased risk of developing osteoporosis due his inability to stand independently.1-3 Considering that Daniel will likely never stand unassisted, maintaining good bone density will prevent him from injury.
Gudjonsdottir and Mercer studied the effects of dynamic versus static standing on bone mineral density in children with cerebral palsy.4 All subjects were non-ambulatory. Half the subjects underwent dynamic standing, the other half static standing. All but one of the subjects showed an increase in bone mineral density in the lumbar spine, proximal femur and distal femur.
Additionally, Goemaere et al compared SCI individuals who conducted standing for one hour, three times per week, with those who did not.5 Bone mineral densities were significantly higher in the long leg bones of the standing group.
Because the glider stander is easy to move from a seated to a standing position, Daniel can easily change his position from sitting to standing. By using the glider feature, he can change his weight bearing amounts frequently.
Lanyon and Rubinl compared static versus dynamic loads and their influence on bone remodeling in animal models.6 They found that static loads did not affect remodeling, whereas a similar load that was applied intermittently in a dynamic manner was associated with a substantial increase in bone mass. Instead of bone loss, the dynamically loaded group demonstrated a mean increase in bone cross-sectional area.
Kawashima, Nakazawa and Akai studied whether passive leg movement in standing was sufficient to improve the oxygenation of lower limb muscles in populations with SCI.7 They compared SCI patients to neurologically normal controls.
Passive movements were performed at different frequencies for three minutes each; then, EMG activity, and oxy- and deoxy-hemoglobin were measured. They discovered that passive leg movements induced not only EMG activities but also an increased oxygen perfusion to the muscle in SCI populations, whereas the controls showed no changes.
This study demonstrates a significant benefit to individuals like Daniel for dynamic standing by showing that the passive movement of his legs in the glider will produce the desired effects.
Walter et al sent questionnaires to individuals with SCI who had purchased standing frames from two different companies.8 Benefits included improved quality of life, decreased urinary tract infections and decreased spasticity, among others. Those who stood for more than half an hour per day showed a statistically significant improvement in secondary complication rates.
Additionally, the study found that compliance for standing with frames or tilt tables is greater than compliance for standing with KAFOs in the home environment.
Considering Daniel's age and his functional level, he will learn to transfer independently into the stander while independently using KAFOs or other type of orthotic for standing is not an option for him. This will increase his usage and thus the benefits of standing.
Follow-Up
Daniel received his new glider stander a few months ago. He uses it regularly and performs five minutes of exercise followed by five minutes of rest a few times while in the stander, with hopes of building up to longer consecutive times as both his strength and endurance improve. The stander is increasing his upper-extremity strength as well as his cardiovascular endurance.
He and his family are happy with their choice and look forward to a lifetime of limited complications from his injury, thanks to regular use of his stander.
References
1. Whedon, G. (1982). Changes in weightlessness in calcium metabolism and in the musculoskeletal system. Physiologist, 25(6), S41-S44.
2. Henderson, R., Kiaralla, J., Abbas, A., & Stevenson, R. (2004). Predicting low-bone density in children and young adults with quadriplegic cerebral palsy. Development of Medical Child Neurology, 46, 416-419.
3. Thompson, C., Figoni, S., Devocelle, H., Fifer-Moeller, T., Lockhart, T., & Lockhart, T. (2000). Effect of dynamic weight bearing on lower extremity bone mineral density in children with neuromuscular impairment. Clinical Kinesiology, 54(1), 13-18.
4. Gudjonsdottir, B., & Mercer, V. (2002). Effect of a dynamic versus a static prone stander on bone mineral density and behavior in four children with cerebral palsy. Pediatric Physical Therapy, 14, 38-46.
5. Goemaere, S., Van Laere, M., De Neve, P., & Kaufman, J. (1994). Bone mineral status in paraplegic patients who do or do not perform standing. Osteoporosis International, 4(3), 138-143.
6. Lanyon, L., & Rubin, C. (1984). Static versus dynamic loads as an influence on bone remodeling. Journal of Biomechanics, 17(12), 897-905.
7. Kawashima, N., Nakazawa, K., & Akai, M. (2005). Muscle oxygenation of the paralyzed lower limb in spinal cord-injured persons. Medicine & Science in Sports and Exercise, 37(6), 915-921.
8. Walter, J., Sola, P., Sacks, J., Lucero, Y., Langbein, E., & Weaver, F. (1999). Indications for a home standing program for individuals with spinal cord injury. Journal of Spinal Cord Medicine, 22(3), 152-158.
Lauren Rosen is a physical therapist and seating and mobility specialist at St. Joseph's Children's Hospital in Tampa, FL. She is program coordinator for the Motion Analysis Center, a three-dimensional motion analysis lab. Additionally, she runs a pediatric and adult seating and positioning clinic. Rosen has been active in DME prescription for the past 15 years, and is chair of the Wheeled Mobility and Seating Special Interest Group of RESNA. She has lectured and written articles on wheelchairs, seating and positioning and standing.