(Article written by Mette Damm Sørensen, PR & Communication, Kebo Care, Denmark)

We know very little about how long and how often wheelchair users should stand to get benefit of standing. The latest scientific research may lead us the way.

- Imagine your doctor prescribe you some medicine and tell you that you just need to take as much as you can. This is not a very professional way to prescribe medicine. Never the less this is the way therapists have ordered stand up training for years.

These were the words from Physiotherapist Erik Bergh during a seminar “Why stand when you can sit” at the REHAB Scandinavia 2005. The latest research show that standing up on a regular basis has a useful effect on many of the secondary diseases most wheelchair users suffer from.

The benefits of standing
- Wheelchair users are not sick because they are sitting in a wheelchair. But they get some secondary diseases from sitting down all the time, which reduces their quality of life substantially and which in some cases lead to premature death, explains Erik Bergh.
Today we know for sure that variation in the positioning and standing up can prevent and reduce the secondary diseases for the wheelchair users and thereby increase their quality of life.
- If the wheelchair user is to maintain a good health and quality of life, standing up on a regular basis is necessary. As therapists we therefore have the responsibility to motivate our clients to stand, says Erik Bergh.

Pressure ulcer is one of the secondary diseases, which today is paid a lot of attention. Pressure ulcers can be prevented by using pressure relieving cushions and by positioning the user correctly in the wheelchair. But the best way to prevent pressure ulcers is to avoid pressure. And the only position where you avoid pressure and have full blood circulation is when you are standing1.

When standing the user also get increased volume in the abdominal and the gravitational pull on the bowels increases the bladder/bowels function. Many wheelchair users report they have less spasm in the underextremities after standing on a regular basis. There are also scientific evidence that standing up has a positive effect on preventing and reducing spasticity2. Also there is good evidence that standing on a regular basis strengthens the bones.

An apple a day
A group of American scientists has examined a Home Standing Programme for Individuals with Spinal Cord Injury3. The results indicate that standing half an hour a day is sufficient to reduce the secondary diseases for wheelchair users with spinal cord injury. However subject to an answer percent of only 32 % of all participants in the programme, the results should not be taken as the finally answer to the “doses” of standing. But compared with other research the half an hour standing can be used as a guideline in practice. According to the different researches standing less than half an hour is not sufficient to reduce the secondary diseases.

Research on standing also indicates that it is better to stand often then to stand only once a day. In other words it is better to stand for 5 minutes at the time then to stand once for half an hour. The question is how to make standing become a natural part of the wheelchair user’s everyday life.

Motivation
Roughly the wheelchair users who benefit from standing can be divided into two groups: Those who do not decide themselves and those who do. The first group who do not decide themselves, therapists and relatives make sure that stand up training takes place. The other group who do decide themselves has to be motivated to stand.
- One of the best motivations to stand is when standing can be combined with something useful, meaningful or social, says Erik Bergh.
Work or daily activities as cleaning, cooking and painting are just some of the activities, which can motivate the wheelchair user to stand. In short there has to be other reasons to stand then “just” the medical ones.
- The wheelchair user is motivated to stand by other reasons then the medical ones. This is very normal and human. I also know, I ought to eat better and to quit smoking but I don’t. I need to have other reasons of social, economic or functional significance, explains Eric Bergh.

Psycho-social significance
So the wheelchair user is motivated to stand, when given the possibility of being active while standing. This makes specific demands to the standing helping aid which needs to be mobile and easy to use. A standing table for example is a simple and affordable solution but also a stationary helping aid, which doesn’t give the user the possibility of being active while standing. The stand-up wheelchair e.g. LEVO is another, more mobile solution which offers the user great possibilities of being active and therefore motivates the user to stand.

Besides the medical and functional reasons for standing, the psycho-social significance is also important. The major part of the respondents in different researches on the psycho-social aspect of standing answer, they feel more socially accepted and less handicapped when standing for one thing: they are at the same eye-level as the surroundings4.

- To be able to participate in different social activities in the upright position gives many wheelchair users a better self-esteem and higher quality of life. And this is what all good therapists strive to give their clients, state Erik Bergh.

1 Swarts A. et al, 1988: Tissue pressure management in the vocational setting.

2 Shields et al, 2002: Muscular, skeletal and neutral adaptions following Spinal Cord Injury.
Shields, 2004: Neuromusculosceletal Plasticity Following SCI. A Paradigm Shift? Nordic Seating Symposium, April 2004.

3 Walter, S. James and others, 2005: Indications for a Home Standing Program for Individuals with Spinal Cord Injury.

4 Eng JJ. et al, 2001: Use of prolonged Standing for Individuals with Spinal Cord Injuries.
Shields R. et al, 2002: Muscular, skeletal and neutral adaptions following Spinal Cord Injury

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