Systematic review and evidence-based clinical recommendations for dosing of pediatric supported standing programs
date: 2013 Fall;25(3):232-47
author: Paleg GS, Smith BA, Glickman LB.
publication: Pediatr Phys Ther.
PubMed ID: 23797394
There is a lack of evidence-based recommendations for effective dosing of pediatric supported standing programs, despite widespread clinical use.
Using the International Classification of Functioning, Disability, and Health (Child and Youth Version) framework, we searched 7 databases, using specific search terms.
Thirty of 687 studies located met our inclusion criteria. Strength of the evidence was evaluated by well-known tools, and to assist with clinical decision-making, clinical recommendations based on the existing evidence and the authors’ opinions were provided.
CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE:
Standing programs 5 days per week positively affect bone mineral density (60 to 90 min/d); hip stability (60 min/d in 30° to 60° of total bilateral hip abduction); range of motion of hip, knee, and ankle (45 to 60 min/d); and spasticity (30 to 45 min/d).
Systematic review and clinical recommendations for dosage of supported home-based standing programs for adults with stroke, spinal cord injury and other neurological conditions
date: 17 November 2015.
author: Paleg G., Livingstone R.
publication: BMC Musculoskeletal Disorders
PubMed ID: 26576548
Sitting for more than 8 h a day has been shown to negatively impact health and mortality while standing is the recommended healthier alternative. Home-based standing programs are commonly recommended for adults who cannot stand and/or walk independently. The aim of this systematic review is to review effectiveness of home-based standing programs for adults with neurological conditions including stroke and spinal cord injury; and to provide dosage guidelines to address body structure and function, activity and participation outcomes.
Eight electronic databases were searched, including Cochrane Library databases, MEDLINE, CINAHL and EMBASE. From 376 articles, 36 studies addressing impact of a standing intervention on adults with sub-acute or chronic neurological conditions and published between 1980 and September 2015 were included. Two reviewers independently screened titles, reviewed abstracts, evaluated full-text articles and rated quality and strength of evidence. Evidence level was rated using Oxford Centre for Evidence Based Medicine Levels and quality evaluated using a domain-based risk-of-bias rating. Outcomes were divided according to ICF components, diagnoses and dosage amounts from individual studies. GRADE and the Evidence-Alert Traffic-Lighting system were used to determine strength of recommendation and adjusted in accordance with risk-of-bias rating.
Stronger evidence supports the impact of home-based supported standing programs on range of motion and activity, primarily for individuals with stroke or spinal cord injury while mixed evidence supports impact on bone mineral density. Evidence for other outcomes and populations is weak or very weak.
Standing should occur 30 min 5 times a week for a positive impact on most outcomes while 60 min daily is suggested for mental function and bone mineral density.
Cardiovascular response of individuals with spinal cord injury to dynamic functional electrical stimulation under orthostatic stress
date: 2013 Jan;21(1):37-46.
author: Yoshida T.
publication: IEEE Trans Neural Syst Rehabil Eng.
PubMed ID: 22899587
In this pilot study, we examined how effectively functional electrical stimulation (FES) and passive stepping mitigated orthostatic hypotension in participants with chronic spinal cord injury (SCI). While being tilted head-up to 70 (°) from the supine position, the participants underwent four 10-min conditions in a random sequence: 1) no intervention, 2) passive stepping, 3) isometric FES of leg muscles, and 4) FES of leg muscles combined with passive stepping. We found that FES and passive stepping independently mitigated a decrease in stroke volume and helped to maintain the mean blood pressure. The effects of FES on stroke volume and mean blood pressure were greater than those of passive stepping. When combined, FES and passive stepping did not interfere with each other, but they also did not synergistically increase stroke volume or mean blood pressure. Thus, the present study suggests that FES delivered to lower limbs can be used in individuals with SCI to help them withstand orthostatic stress. Additional studies are needed to confirm whether this use of FES is applicable to a larger population of individuals with SCI.
Comparison of orthostatic reactions of patients still unconscious within the first three months of brain injury on a tilt table with and without integrated stepping. A prospective, randomized crossover pilot trial.
date: 2008 Dec;22(12):1034-41
author: Luther MS
publication: Clin Rehabil
PubMed ID: 19052242
To determine whether passive leg movement during tilt table mobilization reduces the incidence of orthostatic dysfunction in mobilization of patients being comatose or semi-comatose early after brain injury.
Randomized crossover pilot trial using sequential testing.
Nine patients still unconscious within the first three months of brain injury (5 men, 4 women; age 51 +/- 20 years).
Patients were subjected once to a conventional tilt table and once to a tilt table with an integrated stepping device.
MAIN OUTCOME MEASURE:
The number of syncopes/presyncopes (orthostatic hypotension, tachypnoea, increased sweating) during interventions.
One patient had presyncopes on both devices, six patients had presyncopes on the conventional tilt table but not on the tilt table with integrated stepping, and two patients did not exhibit presyncopal symptoms on either device. There were significantly more incidents on the tilt table without than on the one with an integrated stepping device (P < 0.05) at tilts of 50 or 70 degrees respectively.
Patients tolerate greater degrees of head-up tilt better with simultaneous leg movement.
Investigation of robotic-assisted tilt-table therapy for early-stage spinal cord injury rehabilitation.
author: Craven CTD.
publication: J Rehabil Res Dev
PubMed ID: 23881763
Damage to the spinal cord compromises motor function and sensation below the level of injury, resulting in paralysis and progressive secondary health complications. Inactivity and reduced energy requirements result in reduced cardiopulmonary fitness and an increased risk of coronary heart disease and cardiovascular complications. These risks may be minimized through regular physical activity. It is proposed that such activity should begin at the earliest possible time point after injury, before extensive neuromuscular degeneration has occurred. Robotic-assisted tilt-table therapy may be used during early-stage spinal cord injury (SCI) to facilitate stepping training, before orthostatic stability has been achieved. This study investigates whether such a stimulus may be used to maintain pulmonary and coronary health by describing the acute responses of patients with early-stage (<1 yr) motor-complete SCI (cSCI) and motor-incomplete SCI (iSCI) to passive, active, and electrically stimulated robotic-assisted stepping. Active participation was found to elicit an increased response from iSCI patients. The addition of electrical stimulation did not consistently elicit further increases. Extensive muscle atrophy was found to have occurred in those patients with cSCI, thereby limiting the potential effectiveness of electrical stimulation. Active participation in robotic-assisted tilt-table therapy may be used to improve cardiopulmonary fitness in iSCI patients if implemented as part of a regular training program.
Electrically induced and voluntary activation of physiologic muscle pump: a comparison between spinal cord-injured and able-bodied individuals.
date: 2002 Dec;16(8):878-85.
author: Faghri PD.
publication: Clin Rehabil
To evaluate the central haemodynamic responses during position changes from supine to sitting and during 30 min of standing between able-bodied and spinal cord-injured subjects. Also to assess the effects of the physiologic muscle pump in both groups during 30 min of standing.
A repeated measure design. Both groups were tested on two different days under two conditions of 30 min of stationary standing and 30 min of dynamic standing (voluntary activation of the lower leg muscles in able-bodied and FES-induced activation of these muscles in spinal cord injured). The order of testing was random.
Fifteen healthy able-bodied and 14 healthy spinal cord-injured subjects.
MAIN OUTCOME MEASURED:
Stroke volume, cardiac output, heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure and total peripheral resistance during supine-pre sitting, sitting-pre standing and during 30 min of standing.
Significant reductions (p < 0.05) in systolic blood pressure, diastolic blood pressure and mean arterial pressure were found when spinal cord-injured subjects moved from sitting to standing during stationary standing; these values were maintained during dynamic standing. These values were maintained during both standing sessions in able-bodied subjects. During 30 min of stationary standing, there were significant reductions in stroke volume, cardiac output in both able-bodied and spinal cord-injured while their total peripheral resistance increased (p < 0.05). During 30 min of dynamic standing, both groups maintained their haemodynamics at pre-standing values with the exception of significant reduction in stroke volume at 30 min of standing.
FES-induced activation of the physiologic muscle pump during change in position from sitting to standing prevented orthostatic hypotension in spinal cord-injured subjects. During standing it had equal or even greater effect on improving blood circulation when compared with voluntary activation in able-bodied subjects. The use of FES during standing and tilting in spinal cord-injured individuals may prevent orthostatic hypotension and circulatory hypokinesis and improve tolerance to tilting and standing.
The effects of lower-extremity functional electric stimulation on the orthostatic responses of people with tetraplegia.
date: 2005 Jul;86(7):1427-33.
author: Chao CY.
publication: Arch Phys Med Rehabil
To determine whether application of functional electric stimulation (FES) to lower-limb muscles during postural tilting improves orthostatic tolerance in people with tetraplegia.
A crossover design.
A rehabilitation hospital.
Sixteen acute and chronic subjects with tetraplegia (15 men, 1 woman) with complete motor function loss at the C3-7 levels were recruited. Time since injury ranged from 2 to 324 months (mean, 118.9+/-104.2 mo).
Subjects were tested on a progressive head-up tilting maneuver with and without the application of FES at 0 degrees , 15 degrees , 30 degrees , 45 degrees , 60 degrees , 75 degrees , and 90 degrees continuously for up to 1 hour. FES was administered to 4 muscle groups including the quadriceps, hamstrings, tibialis anterior, and gastrocnemius muscles bilaterally at an intensity that provided a strong, visible, and palpable contraction. This was to produce a muscle pumping mechanism during the tilting maneuver.
MAIN OUTCOME MEASURES:
Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate, perceived presyncope score, and the overall duration of orthostatic tolerance, that is, the time that subjects could tolerate the tilting maneuver without developing severe hypotension or other intolerance symptoms.
When the tilt angle was increased, the subjects’ SBP and DBP tended to decrease, whereas the heart rate tended to increase in both testing conditions. Adding FES to tilting significantly attenuated the drop in SBP by 3.7+/-1.1 mmHg (P = .005), the drop in DBP by 2.3+/-0.9 mmHg (P = .018), and the increase in heart rate by 1.0+/-0.5 beats/min (P = .039) for every 15 degrees increment in the angle of the tilt. FES increased the overall mean standing time by 14.3+/-3.9 min (P = .003).
An FES-induced leg muscle contraction is an effective adjunct treatment to delay orthostatic hypotension caused by tilting; it allows people with tetraplegia to stand up more frequently and for longer durations.
author: Chelvarajah R.
Upright posture confers numerous medical and social benefits to a spinal cord injured (SCI) patient. Doing so is limited by symptoms of orthostatic hypotension. This is a common secondary impairment among tetraplegic sufferers.
Establish the proportion of SCI patients who are restricted from using standing apparatus, such as standing frames and standing wheelchairs, because of inducing symptomatic orthostatic hypotension or the fear of developing these disabling symptoms.
Survey conducted by Internet-accessible electronic questionnaire. Questionnaire validated for reliability and accuracy.
293 respondents. Mean age 44.6; 76% male. Median time from injury: 7 years. 38% suffered with orthostatic hypotension; majority were complete injuries and all (except one – T12) were T5 or above level. 52% replied that they were using standing wheelchairs or frames. Of these, 59 (20% of total) stated that orthostatic hypotension symptoms were limiting the use of their upright apparatus. Of those who did not use standing wheelchairs or frames, 16 (5.5% of total) reported that this was because of the fear of worsening their orthostatic hypotension.
Orthostatic hypotension restricts standing apparatus use in a large proportion (a total of 25.5% of respondents in this survey) of SCI patients.
Weight bearing through lower limbs in a standing frame with and without arm support and low-magnitude whole-body vibration in men and women with complete motor paraplegia
date: 2012 Apr;91(4):300-8. doi
author: Bernhardt KA
publication: Am J Phys Med Rehabil
The aim of the study was to determine the proportion of body weight borne through the lower limbs in persons with complete motor paraplegia using a standing frame, with and without the support of their arms. We also examined the effect of low-magnitude whole-body vibration on loads borne by the lower limbs.
Vertical ground reaction forces (GRFs) were measured in 11 participants (six men and five women) with paraplegia of traumatic origin (injury level T3-T12) standing on a low-magnitude vibrating plate using a standing frame. GRFs were measured in four conditions: (1) no vibration with arms on standing frame tray, (2) no vibration with arms at side, (3) vibration with arms on tray, and (4) vibration with arms at side.
GRF with arms on tray, without vibration, was 0.76 ± 0.07 body weight. With arms at the side, GRF increased to 0.85 ± 0.12 body weight. With vibration, mean GRF did not significantly differ from no-vibration conditions for either arm positions. Oscillation of GRF with vibration was significantly different from no-vibration conditions (P < 0.001) but similar in both arm positions.
Men and women with paraplegia using a standing frame bear most of their weight through their lower limbs. Supporting their arms on the tray reduces the GRF by approximately 10% body weight. Low-magnitude vibration provided additional oscillation of the load-bearing forces and was proportionally similar regardless of arm position.