What are the Indications and Contraindications for a Standing Program?

This is a guest post on the EasyStand Blog by Peter Wankelman. This post will be of interest to physical therapists and physicians, and others with a clinical background.

My name is Peter Wankelman and for the past 15 years I have earned the reputation as the “Altimate” Road Warrior. In that time as an employee of Altimate Medical my schedule has often been two to three weeks in the field working with RTSs and Therapists in schools, clinics and hospitals – evaluating, fitting and in-servicing standing devices. I have lectured on the benefits of standing in over 150 cities in six countries. I am not a clinician or licensed medical professional; I am only sharing what I have seen and been told by therapists and physicians whom I have worked with in respect to clinical indications and contraindications of a standing program.

Early in my career I worked with and became friends with a superbly qualified, dedicated and respected school physical therapist of thirty-plus years. She told me, “Anyone, who uses a wheelchair for his or her mobility, is indicated for a standing program except when specifically contraindicated.”

Indications for a Standing Program

The literature clearly suggests that an individual at risk of immobilization syndrome is indicated for a standing program unless specifically contraindicated. The medical benefits of a lifetime of standing compliance are well documented; I have been told by therapists and physicians that standing is shown to have a positive impact on virtually every major system of the body.

Standing is known to help prevent or reduce hip flexion, knee flexion and plantar flexion contractures – helping to maintain joint range of motion. Standing is shown to reduce the incidence of upper respiratory infection, a leading cause of death for children with a cerebral palsy diagnosis. Standing is shown to reduce the incidence of urinary tract infection, prevalent with a spinal cord injury diagnosis. Standing is shown to help to maintain bone mineral density, and the list goes on. Standing programs have been shown to have a positive impact in tests of cognition; effecting educational and vocational outcomes.

Medical professionals tell us a standing program is indicated for a child with a disability at about one year of age, or approximately the same age that typically developing peers are pulling themselves to a supported standing position. To minimize the risk of immobilization syndrome, the standing program should continue through the individual’s lifetime provided the person is not contraindicated.

Contraindications to a Standing Program

Anyone considering a standing program should consult with a qualified physician and medical team to determine what indications or contraindications exist. Clinicians should use their best clinical judgment to determine if weight bearing/standing is indicated on an individual client basis.

Contraindications may include orthostatic intolerance syndrome: orthostatic hypotension, elevated heart rate or other cardiovascular conditions. Yet, I have evaluated and fitted standing devices, prescribed by physicians to help strengthen an individual’s cardiovascular system. Immobilization puts the cardiovascular system at risk. Case studies show standing tolerance can be increased over a relatively short period of time with compliance to a standing program.

People with impaired skeletal structure may be contraindicated for a standing program. Osteogenesis imperfecta, osteoporosis or other forms of brittle bone disease may be a clear contraindication for certain people. Yet, I have worked with physicians and therapists, evaluating and fitting standing devices for individuals with impaired skeletal structure with a desired outcome of maintaining or increasing bone mineral density.

Impaired range of motion or severe contractures can be a contraindication of standing in some cases. However, a regular standing program has shown to improve range of motion and decrease contractures. Again, individual client assessment is necessary.

Standing clients with hip subluxation may be another contraindication. However, I have worked with highly respected therapists who, when working together with a physician, determined a standing program was indicated for that individual with better hip socket location as a desired outcome.

Other contraindications may exist; medical professionals must be consulted in determining each individual’s indications and contraindications for a standing program.

Use Clinical Judgment to Evaluate the Individual Needs

Implementing a standing program must be determined on an individual basis by the team (physician, physical therapist, RTS, consumer, etc.). Consider the contraindications and indications of each of your clients individually to determine if weight bearing/standing is an option for them. Don’t rule a standing program out because your last client with a similar diagnosis couldn’t stand.