Why should you stand regularly following a spinal cord injury?
You may not think of ‘just standing’ as a form of exercise but it is both an effective and practical method for most people following a spinal cord injury as we reveal in this article. People who cannot walk or stand unaided due to a spinal cord injury often must sit for more than 8 hours a day, and as a result are at risk of secondary complications. These complications are well known and include the development of pressure ulcers, limb contractures, weakened bones, compromised circulation and blood pressure and aggravated bowel and bladder function. In addition, an improved sense of well-being and improved quality of life are associated with standing. Whilst interventions such as physical therapy, specialist seating cushions, muscle stimulation etc can mitigate some of these complications, regular standing appears to be a practical preventative step that most persons should take following a spinal cord injury.
For this reason, passive standing is encouraged by clinicians as soon as rehabilitation starts with the aid of a product or structure that can typically stabilise at least the hips, knees and ankles. Commonly used methods include so called standing frames, standing wheelchairs and orthoses. The ease with which these can be used varies with the nature of the injury. A low level, incomplete spinal cord injury may make orthotic interventions such as a knee ankle foot orthosis (KAFO) more practical for example. Higher level injuries such as cervical or thoracic will generally require support for the trunk as well as the legs when standing.
Standing regimes
Supported standing programs have been integrated into clinical practice for over 50 years and all patients should be individually assessed for the potential benefits of standing. The benefits are generally considered to be dependent on patient presentation (level of injury to the spine), time since injury and patient preferences. Evidence-based guidelines defining how long or how often adults with spinal cord injury need to stand to have been published (MASCIP, 2013)
Paleg and Livingstone (2015) reviewed the literature and noted that stronger evidence underpins the impact of regular standing programs on range of motion and activity for both stroke and spinal cord injury populations with some mixed evidence supporting impact on bone mineral density. Evidence for other outcomes is weak or very weak.
Suggested dosage
Dosage data suggests that the use of a standing device should occur for thirty minutes, five times a week for positive impact on most outcomes such as self-care and standing balance, joint ranges of motion, cardio-respiratory, strength, spasticity, pain, skin and bladder and bowel function.
Sixty minutes for 4-6 times a week may be required for positive impact on bone mineral density and mental function.
While therapists can recommend with some confidence the use of a supported standing intervention to impact on preserving joint range of motion and activity outcomes, the evidence is less certain for other outcomes. It makes sense that outcomes should be measured to ensure effectiveness for individual clients.
Product choices
The most commonly seen product in the UK is perhaps the standing frame which comes in various guises such as the wooden 'Oswestry' frame or the more modern 'EasyStand' designs. These achieve the basic objectives of allowing a person with lower limb paralysos to stand and may also allow other passive activities to take place at the same time. They need to be set up for the stature of the individual and steps taken to make it as easy and safe as possible to transfer on and off. The biggest objection we hear is that they can take up too much space in modern houses and are a bit 'boring' to use. The problem with being boring is that this is not exactly an incentive for regular use.
Standing wheelchairs have the advantage of allowing much easier and more frequent use as they combine two needs. The person can move around and stand when they need to with power assistance. Being mobile is definitely a big positive benefit although standing wheelchairs do tend to have a large wheelbase and the standing posture will typically be inclined back to some extent in order to maintain stability when in a standing position. For this reason they tend not to be most useful for prolonged standing. There are even specialist powered chairs for activities such as golf.
KAFO's or other non-powered orthotic products may be used by persons with an incomplete injury and some necessary and sufficient preserved muscle function. Modern materials such as carbon fibre have reduced the overall encumberance due to weight but there will be a need to use a rollator/walker or forearm crutches which means that the hands and arms are not free to participate in other activities. Orthoses should be custom made to a model of the person's limbs to avoid problems of pressure or rubs at the tissue interface. Conventional orthoses tend to be passive structures with joints, at least at the knee, which are locked during gait and unlocked when seated. Some KAFO's can have knee joints that automatically lock and unlock via electromechanical means but these are less frequently seen.
Exoskeletons and powered orthoses may extend their value to certain individuals but their cost will put them out of reach for many. There are different drivers for adoption of the technology in different countries. For example, in the USA, qualifying injured veterans of the armed forces can be provided with an 'approved' exoskeleton such as the Indego without charge to them. No such initiatives exist in the UK.
Indego Exoskeleton
The User of an Indego Exoskelton will typically use some form of walking aid - a rollator or arm crutches as shown here. This model can provide motive power for a complete spinal cord injury or provide controlled support in the case of a complete injury.
Since their introduction for spinal cord injured people, exoskeleton products have suffered to some extent from inflated expectations for their function and value. Of course there are a growing number of these in development (more than a hundred) and on the market so we can expect to see some of these find a place and others disappear.
Where there is some potential for functional improvement (ie with an incomplete spinal cord injury) then only some of the current exoskeletons can provide a truly restorative function. This is because the balance between the effort the user makes and the exoskeleton makes must be adjustable to have a training effect. The buyer needs to beware and make sure that a product’s claims are really justified as the restorative possibilities do vary significantly from product to product. For example, the Indego can utilise different software modes to support a broad spectrum of user functions from essentially absent motor function through to normal motor function.
If the user has a complete injury and truly has no potential to recover function, then an exoskeleton will have to provide all of the propulsive power as well as the structural stability to support the limbs. It will be acting purely as an assistive product, compensating in totality for the lost function.
We are also starting to see the emergence of wearable, textile-based exoskeletons. These softer, more compliant structures are not as likely to be helpful for a complete spinal cord injury as they cannot generate the necessary mechanical forces to stabilise the limbs for gait but could be beneficial for some neurological conditions such as MS or post stroke.
The repetitive impact loading generated by gait training in an orthosis or exoskeleton that puts the user directly in touch with the ground may lead to greater benefits in terms of bone mineral density and bowel and bladder function when compared with other approaches to standing.
Alternative approaches
Less well known is the unique, Tek RMD from Matia Robotics. It is neither a standing wheelchair nor a passive standing device but a unique product that can allow users with a spinal cord injury or other neurological injury to readily stand and move in an indoor or outdoor environment. The user of the Tek RMD can now largely have hands free to engage with their environment.
Unlike the typical standing wheelchair, the user is not tilted back when standing upright so that for most users a perfect therapeutic posture can be achieved and held for longer periods. Thick pads are positioned just below the knee and at the chest and a seat cushion spans the hip area so that the user is safely held whether fully upright, seated or at any point in between. This balanced posture allows much easier interaction with the environment. Many users find that they can at last use a standard kitchen layout and they can at will move from picking something from a high shelf or a low cupboard.
The Tek RMD is shown equipped with outdoor wheels for greater stability. The user can move easily from sitting to standing position and use the joystick to move around in an upright position at walking speeds.
Each Tek RMD is setup to suit the stature of the individual user; some people need more trunk support initially and the product can be reconfigured as the user's requirements change over time. What surprises many users is that the product is both narrower and shorter than their typical wheelchair so it is very easy to manueouver. Using the control panel the user may sit or stand and use the joystick to stear around their environment.
Transferring on and off the Tek RMD is rather unique too. The product is boarded from the back. Some users can transfer from a wheelchair although this may depend upon the design of the chair and the persons transfer abilities. Others prefer to use a height adjustable plinth or even a conventional chair. The manufacturer recently released a transfer seat which provides another alternative. It flips down for use and flips up for convenience when not needed.
Until recently the Tek RMD used a manual operated gas spring design to make rising to a standing posture easier. This required the user to squeeze handle bar levers. This generally was only be ideal for paraplegics as moving from sitting to standing would require good hand and arm function. Many persons with high level injuries or conditions such as MS or post-stroke would not be suitable for the manual version. With the arrival of the electric lifter version most potential users may very easily operate the product with minimal hand and arm function. Once upright the user can move around simply by using a joystick control.
Initially envisaged as an indoor use product the manufacturer has now released the outdoor wheels kit that easily transforms the Tek RMD to be suitable for grass and other surfaces. The kit allows many wheelchair users to quickly and easily change their product for indoor or outdoor use as the mood requires.
The Transfer Seat
The transfer seat can be flipped down to facilitate transfer from a wheelchair
We can't ignore the cost of the technology with exoskletons, standing wheelchairs and the Tek RMD being significantly more expensive than the purely standing options. We have found that the Tek RMD has allowed some users to return to work and by this means they have been able to access some sources of public funding.
Domestic users should find that they can achieve a good balance between social and therapeutic benefits by using the Tek RMD. It is always a good idea for people in the market for these products to understand that each product will have different strengths and weaknesses and no product can be perfect for everyone. There are good clinical reasons to make standing part of life and weigh up the most suitable way of achieving this in each individual case.
Learn More and book demonstrations of the Tek RMD here.
References
MASCIP (2013) Clinical guideline for standing adults following spinal cord injury. Spinal Cord Injury Centre Physiotherapy Lead Clinicians United Kingdom and Ireland
Paleg, G., Livingstone, R. (2015) Systematic review and clinical recommendations for dosage of supported home-based standing programs for adults with stroke, spinal cord injury and other neurological conditions. BMC Musculoskelet Disord., 16, 358 (2015). https://doi.org/10.1186/s12891-015-0813-x