Standing as Therapy

Posted by Nurse Linda in Life After Paralysis on May 14, 2021 # Health

Standing may seem like an unusual suggestion after paralysis, but it can be accomplished. Equipment is needed to achieve the goal. The benefits are numerous.

The benefits of standing include mental wellbeing. It can be surprising to individuals and families that standing has such an impact on psychological health. Seeing yourself upright for the first time in a while can be an emotional moment. You might have forgotten what you looked like standing, how tall you are or what it is like to be as high as others. Every individual and family have their own response.

Other benefits include cardiac functioning, lung expansion, pressure relief, muscle stretching, spasticity control, bowel and bladder effects and bone health. These issues have been studied with varying outcomes. The point is that effects on the body are all in the direction of improvement in system functioning.skeleton diagram

Equipment is needed for standing. The most basic is a standing frame. In this device, the individual transfers onto a seat with a back. There is a place for foot placement. Straps or restraints are used to support key joints in the body to provide stability for standing. A wide strap restraint is placed around the knees. A strap and the seat will double as support for the hip. If you have a higher-level injury, a chest restraint, arm supports, or head support will be needed. A pump is used to bring the supported individual to a standing position. The pump may be manual, pneumonic, or electric. Braces can also be used for standing.

Some standing frames come with a tray and water holder so you can do other things while standing. Some versions can be wheeled around for movement. More advanced options include gliders so you can use your arms to reciprocally move your legs. Advanced wheelchairs have a standing option that can put you at eye level with others, especially in social situations.

The best option is the standing equipment that you can obtain. Standing is becoming more traditional in therapy. You can request a standing frame through your health professional. Many payors recognize the benefits of standing and are supporting individuals with supplying the basic equipment and therapy to learn to use it. Check your policy as you might have a benefit for this type of equipment. More often, your first request will be rejected. Appeal or, possibly, several appeals might need to be made.

Before you begin standing, check your health status with your healthcare professional. You may need a bone density test to ensure your bones can support the weight of your body. Also, an assessment of your joints for contractions is necessary. Your joints need to be able to support your body weight and for alignment. A check of your blood vessels will ensure there is not a clot lurking that could become dislodged. Also, an assessment of your cardiac health will ensure you are up to the physical challenge of standing.

Time may be needed to begin standing. Your body has adapted to being seated or in bed. Standing will take some adjustment. Thinking back to your first rehabilitation days, getting to a seated position may have been a challenge due to orthostatic hypotension (OA) (low blood pressure). It is difficult for the heart to pump blood effectively to the head with issues of the autonomic nervous system. That is the part of the nervous system that works automatically, without your thinking about it. When your body changes position, the blood vessels in the legs automatically constrict to pump more blood to the head for the upright transition. Without signals sent to the brain effectively, the blood vessel constriction is sluggish and may not be effective, which triggers OA. You can become dizzy, lightheaded, or even pass out if too aggressive with becoming upright.

To avoid becoming dizzy, lightheaded, or passing out, begin slowly. Your first time in the standing frame may just be getting into the equipment. Over time, you might be able to elevate your body 10%, then 20%, then incrementally until standing. This can take time, just as becoming upright was back in your early rehabilitation. Use elastic stockings to help the blood vessels in your legs to constrict. An abdominal binder will also assist with blood flow return. You may have gotten rid of these supports or they may be in a drawer. Elastic does not remain taught for long periods of time. It can rot with washing or lack of use. A good plan is to get new elastic stockings and a binder, so you have maximum support to begin the standing process.

Know your average blood pressure. Blood pressure effects are a good measure of cardiac function. Assessing your blood pressure as you develop the standing ability will help you see how far you should progress at any one time. If your blood pressure lowers, or raises from your personal normal, you will know to go slower.

Standing supports puts pressure on different places of your skin. The best example is the knees. Not many individuals have pressure injuries on their knees because that is not an area that is used in sitting or bed positioning. Now, there is a strap restraint over your knees with pressure. The skin here is not used to that. The same is true for wherever pressure is now applied to your body.

A pressure injury can occur within minutes. Check your skin frequently while you are building your standing tolerance. You are also building skin tolerance. Any red area should not have pressure until it resolves. Other areas to monitor include the strap restraint area on your bottom, back support area, chest, headrest if used, and your arms, where you might be resting them differently due to your new position. Check your feet as well, as they will fit differently in your shoes with standing. There is the padding on the seat and backrest of most standing equipment. However, it might not be the weight dispersion you need. You may need an advanced pad or, if you can, safely use your own seat cushion during the process. A pressure injury can slow the progress of standing or halt it altogether. Vigilance is needed to ensure no pressure injury, even just a small dot, occurs. Pressure dispersing equipment can be added, and straps can be adjusted.

As with any changes in your routines, autonomic dysreflexia (AD), increases in tone (spasticity), or pain can occur. You may not have a direct sensation of standing, including fatigue or a strap being too tight, body out of alignment, or any other issue. But your body will react, sometimes through these alternate warning systems. These will not preclude you from standing but do require treatment. Slowing the process of standing may help and use your treatments for these issues that you normally use. If these sensations develop with standing, you will need to check with your healthcare professional to provide treatment or alterations in your standing routine.

As you stand, gravity will have wonderful effects on your body. Your lungs will be able to inflate and deflate with deeper breaths. That might feel 'funny' to you. Coughing and deep breathing can really help clear those tiny pathways in the lungs once you are used to standing.

Your bowel and bladder program may have effects from standing. Gravity assists both processes. Added with the movement of changing positions to get into the standing position and back to seating can affect your bowel and bladder positively. You might find a quicker bowel program. Increased urine output can occur, especially during standing. Be sure catheter tubing is free and external catheters are correctly placed.

Along with bowel function, digestion, in general, has been noted to improve with standing. Stretching the body's torso, along with gravity, helps to empty the stomach and assist with moving food along the digestive tract.

Muscles of your body have stretch receptors within them. These receptors are constantly attempting to send messages that they want movement. Tone (spasticity) results from miscommunicated messages and this need for muscles to stretch. Standing provides stretches muscles are seeking. Tone (spasticity) and pain may be reduced by standing and fatiguing those muscles. Do not be surprised if you find that you are tired after standing at first. Your body is working even if you do not have that sensation of muscle fatigue. Overall, this is a workout for your muscles, not from movement but from the weight. The body will like this input.

Joints will be stretched while standing. It is important to think about your position sitting. The hips and knees are at 90° angles. When laying on your side, more than likely, they are at 45°angles. Standing straightens the joints of the hips and knees, avoiding contractures.

Muscle stretching and visually seeing yourself standing are excellent mental wellness activities in addition to the physical benefits of standing. Enjoy the moment but know it takes a while for the positives to set in. Some individuals adapt to standing quickly, and others take more time. How quickly you will adapt to standing is based on several factors, including the type of injury, length of time since injury, your age and general health status, all the usual factors. But you will accomplish the standing goal. Do not compare your progress to others as you are a unique individual. Nurse Linda

Pediatric Consideration:

Standing is available to children from toddler age and above. It can assist with developing skeletal bones by providing weight through them. Children's equipment is a challenge from the point of view that it is ordered to anticipate that it will last a number of years. However, as you are well aware, children do not remain the same size for long. Some equipment comes with a certain amount of 'growth spurt' room. Others do not. Work with your equipment provider to ensure growth room.

Standing equipment that has mobility is a great advantage in the classroom when activities for moving around are needed. Be sure to include educational advantages in your equipment request. Nurse Linda

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.

This project was supported, in part, by grant number 90PRRC0002, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.