Standing Tall: Examining the Evidence for Standing Power Wheelchairs

Many of us have come across news articles and research discussing the detrimental effects of prolonged sitting on our health. The risks associated with extended sedentary behaviour are widely recognised, and we are now beginning to understand how standing can impact our health, including for individuals who use wheelchairs. In the latest guidelines, people with mobility impairments are advised to limit their sedentary time and replace it with any form of activity, as numerous studies have demonstrated the health benefits of such a change⁹.

While technology has offered the integration of standing with mobility devices for several decades, it's only been in the last fifteen years that wheelchairs have become more accessible with standing capabilities. Issues like compatibility with wheelchair seating, mechanical adjustability, and programming have been effectively addressed, making standing wheelchairs more viable. Power standing refers to a system that allows a standing feature, consisting of multiple actuators and power seat functions like tilt, recline, elevating legs, and seat elevation, to be fully utilised on a power wheelchair base. This combination of seat functions and power base enables wheelchair users to easily transition between sitting and standing positions, granting them improved access to their surroundings¹³.

As the prescription of wheelchairs with standing capabilities become more common alongside our increasing knowledge of the importance of standing, it becomes essential to explore the clinical evidence supporting the benefits of power standing wheelchairs across various domains of impact. 

In this blog post, we heavily draw upon the research and insights provided by Permobil's White Paper on Power Standing. Throughout this article, we reference their work extensively and encourage readers to explore the source for a more in-depth understanding.

Participation and quality of life

Traditionally, living environments and workspaces have been designed under the assumption that activities will be performed while standing, hence the heights of kitchen benches/counters, bathroom sinks, storage cupboards, handles, and light switches. Although there have been some advancements in understanding universal design and aging in place, this practice is not yet widely adopted as a standard¹³. Unfortunately, for individuals who use a wheelchair and function at a seated height, these typical living and workspaces often become inaccessible¹³. Multiple studies have highlighted the benefits of power standing in various settings and environments as a way to increase accessibility and participation.

Two studies conducted among children and adults using power standing wheelchairs revealed that all participants experienced increased satisfaction in daily life activities, including personal care routines, household chores, leisure pursuits, food preparation, singing in a choir, performing in plays, working in stores, dining at restaurants with bar-style seating, participating in school activities, and engaging in outdoor play^25,33.

For individuals with Duchenne Muscular Dystrophy, standing proved advantageous for both teaching and other activities at school, and it enabled faster toileting, resulting in less time missed from class²¹. Another study involving individuals with Duchenne Muscular Dystrophy reported that power standing was beneficial in both home and school environments, with the potential to improve participation, although this was not directly measured in the study²⁸.

Power standing has also been shown to facilitate face-to-face communication for wheelchair users in multiple studies^21,33,15. This feature in power wheelchairs offers an improved quality of life by enabling users to interact at the same level as their peers, making social interactions easier. Standing wheelchair users have noted that this enhancement to their quality of life is one of the most significant benefits¹. Furthermore, parents of children using power standing wheelchairs have observed that power standing enables better communication and hearing for wheelchair users in various qualitative studies^21,33,27, alongside increased self esteem and the advantage of being able to engage face to face with others²⁵.

In adolescence, when mental health can often decline, using a power standing wheelchair has been associated with improved self-reported scores, reflecting a more positive mood, reduced hyperactivity, and improved peer relations²⁶. Adolescents receiving power standing wheelchairs reported feeling happy, excited, and more independent, as they enjoyed performing tasks without constantly seeking help from others²⁷.

Functional reach and activities of daily living (ADLs)

The advantages of increasing reach and improving visual orientation are comparable in both standing and seat elevation, as they allow individuals to position themselves closer to higher-placed objects and visualise items at the same height^1,29,30. Additionally, reduced over-shoulder reaching may contribute to less shoulder pain or injuries³¹. Apart from the direct impact of standing on activities, there may also be indirect benefits. For instance, a decrease in spasticity resulting from standing might lead to improvements in activities of daily living (ADLs) such as bathing³².

Power standing has demonstrated significant improvements in various activities for children and adults. Tasks such as hugging someone, stirring pots on the stove, reaching water in the kitchen sink, exercising, and cleaning the house have been positively affected²⁰. Driving in a standing position has allowed individuals to assist with chores more easily and increased their independence in various tasks²⁰. Adolescents with Duchenne Muscular Dystrophy have experienced faster personal care routines and reduced reliance on hoists and transfers while power standing. The ability to pass urine in a standing position has proven easier and quicker, leading to increased independence in toileting^21,26. Among non-ambulatory boys with Duchenne Muscular Dystrophy, power standing has been predominantly used for independent toileting²⁸. Other standing activities include classroom activities, sports, dance, outdoor play, cooking, and countertop tasks²⁸. Additionally, power standing has been employed in physical education activities like table tennis, archery, and golf²¹.

In a qualitative study focusing on children with various diagnoses using power standing wheelchairs, the ability to stand when and where desired was found to enhance children's independence in performing tasks, such as washing hands, and allowed them to feel more involved in certain activities²⁵. The impact of standing on reach has been consistently observed in multiple studies, with power standing improving individuals' ability to reach items on high shelves at home and groceries in stores²⁰. Boys with Duchenne Muscular Dystrophy reported increased access to higher shelves, cabinets, and counters²⁷, while the same qualitative study emphasised the increased ability to reach things for children with different diagnoses²⁵.

Pressure injury prevention

There are a limited number of studies specifically focused on the use of standing wheelchairs for pressure injury prevention, but there is a broader body of evidence examining non-device specific standing. Allowing individuals to reposition in standing can lead to improved skin integrity by reducing pressure on bony prominences typically loaded when seated, such as the ischial tuberosities and sacrum, and facilitating oxygenated blood flow to these areas^1,5.

Studies have shown that standing can reduce pressures on the seated area by up to 40%⁵. Both standing and recline options offer similar seat load reductions, but compared to tilt and recline, standing is the only configuration that decreases loads off the seat and backrest simultaneously⁵.

Considering the role of shear in pressure injury development is crucial. Shear occurs when body tissues move in relation to the surfaces of the seating system, such as the back sliding up the wheelchair back support during recline. The sit-to-stand movement generates shear forces on the seat and back support¹⁴. Shear forces can potentially increase the risk of pressure injuries and require careful attention. Fortunately, most power wheelchairs with power seat functions are equipped with an anti-shear mechanism to mitigate this risk. Without an anti-shear mechanism, there is an increased risk of shear forces both when standing up and returning to a seated position¹⁵.

Pain

Pain is reported as the most prevalent comorbidity affecting individuals who use mobility devices, impacting approximately 91% of users¹⁶. Nevertheless, there is conflicting evidence regarding the impact of power standing on pain.

Among the four trials that investigated power standing wheelchairs and reported on pain, two revealed favourable effects^26,20, while the other two indicated unfavourable effects^27,28. The favourable effects included reports of no pain or discomfort in children with cerebral palsy and reduced pain levels in adults with spinal cord injury or multiple sclerosis after six months of using a power standing wheelchair²⁰. In another trial involving adolescents with Duchenne Muscular Dystrophy, participants reported pain, but this pain was not specifically attributed to standing in the power wheelchair²⁶.

On the other hand, the unfavourable effects of pain included adolescents with Duchenne muscular dystrophy experiencing pain while standing in the power wheelchair. Pain locations were primarily ankles, knees, and calves, and pain occurred during 15-44% of the standing occasions²⁸. In another trial among individuals with Duchenne Muscular Dystrophy, standing time within a session had to be reduced due to pain in the foot, anterior knee/shin related to pressure from support pads, and back pain. However, it was observed that physical discomfort experienced during power standing did not persist beyond the daily standing times²⁷.

Range of motion

The reduced range of motion (ROM) experienced by wheelchair users can lead to various challenges, such as pain, discomfort, limitations in positioning, difficulties with self-care tasks, and a decline in functional independence¹³. Thus, maintaining existing ROM is crucial for supporting their function and independence, particularly for individuals who are full time wheelchair users¹³.

For non-ambulatory individuals, a power standing wheelchair offers a way to move within their available ROM, as it allows passive movement of the hips, knees, and trunk. When seated in the same position day after day, muscles can either shorten or lengthen to adapt to that posture. However, standing engages those muscles and helps prevent contractures^1,2,4,6,7.

Spasticity 

Spasticity is a condition that arises from an impaired neurological system, leading to disruptions in movement patterns. This condition can result in stiffness or tightness in the muscles, restricting fluid movements¹³.

Systematic reviews on standing in other devices have shown that the available evidence is weak, but it suggests a positive effect of standing on spasticity^8,12,23,24. Studies conducted among children with cerebral palsy using clinical assessments, such as the Ashworth Scale, also indicate positive effects of standing in reducing spasticity²³. Additionally, surveys among individuals with spinal cord injury suggest a potential positive impact of standing on spasticity¹².

Bladder and bowel function

In individuals using a power wheelchair, incontinence and bowel issues are common co-morbidities¹⁶. Remaining seated for extended periods can lead to incomplete bladder emptying, resulting in urinary tract infections and leakage⁷.

Similarly, the gastrointestinal system can be affected in wheelchair users, especially those with neurological disorders. Immobilisation and paralysis often contribute to constipation, as seen in individuals with spinal cord injury and neurogenic bowel dysfunction. This dysfunction may involve difficulties in elimination or storage. Research in able-bodied individuals without bowel dysfunction has shown that food empties from the stomach more efficiently when they alternate between sitting and standing, compared to just sitting, standing, or lying down¹⁷.

Challenges in managing bowel function due to disruptions in the central nervous system, impaired mobility, and hand dexterity not only lead to physical limitations but can also present psychosocial difficulties¹⁹. Moreover, individuals with spinal cord injury may face the medical emergency of autonomic dysreflexia, which can be triggered when the bowel or bladder fails to empty¹⁹.

Several studies among individuals using power standing wheelchairs support the positive impact of power standing on bladder and bowel function¹³. In one case-series, four participants who reported constipation before using a power standing wheelchair showed improvements in constipation quality of life measures after adopting the power standing wheelchair²⁰. Another retrospective data review involving 13 individuals using power standing wheelchairs found a lower incidence of urinary tract infections in the year after adopting the power standing wheelchair, compared to the year before¹⁶. A qualitative study revealed that parents of adolescents with Duchenne Muscular Dystrophy observed improved digestive function after their children started using a power standing wheelchair²¹. Similarly, different stakeholders, including children using power wheelchairs, their parents, and clinicians, agreed in another qualitative study that power standing wheelchairs have a positive effect on bowel and bladder function²².

Respiration and circulation

When in a seated position, many internal structures and organs are compressed, making every day physiological processes less efficient. On the other hand, standing allows these organs to be free from compression, and the force of gravity can aid in internal physiological processes¹. However, the effects of standing on cardiorespiratory function remain relatively unknown, and there is limited evidence regarding the impact of power standing on cardiorespiratory function and oedema¹³.

Some parents of adolescents with Duchenne Muscular Dystrophy who used power standing wheelchairs reported that their children experienced easier breathing, allowing the lungs and diaphragm to fully expand and contract, although this observation was not quantified further²¹. In another qualitative study, respiratory and cardiovascular benefits were mentioned among perceived health improvements due to power standing, but specific details were not provided²⁵. None of the other studies on power standing reported on these outcomes. In the case of standing in other devices, a few studies in adults examined cardiorespiratory function, but the available evidence was weak¹².

Bone density

Standing and weight bearing can lead to improved bone density, as they help maintain bone density, which tends to decrease during periods of inactivity or prolonged sitting^1,3,8.

A recent systematic review, considering evidence on power standing and standing with other devices in children and adolescents with non-ambulatory cerebral palsy, reported predominantly positive findings. It highlighted the importance of interpreting these results in the context that children without the ability to walk are prone to developing osteoporosis and experiencing declining bone density with age²³. Similar conclusions were drawn from systematic reviews on the evidence of standing with various devices in adults, where studies showed either maintenance or improvements in bone density^12,8,24.

Other domains of impact

People have reported positive impacts of power standing on motor function, muscle strength, balance, sensation, fatigue, blood sugar, postural changes, and sexual health, however there is currently limited evidence to support this¹³. 

Integration into daily life

While many individuals use a standing frame in conjunction with a non-standing wheelchair, integrating standing into a person's primary mobility device offers several benefits. With an integrated standing power wheelchair, individuals can independently transition into and out of a standing position, perform tasks while standing, and even drive while standing, enhancing their ability to sustain a standing regimen¹. This integrated approach may make it easier for individuals to engage in multiple standing sessions throughout the day for shorter durations compared to using a separate standing frame. However, certain contraindications for standing must be considered, such as orthostatic intolerance, impaired skeletal structure intolerant to standing, osteoporosis, osteogenesis imperfecta, or hip and knee flexion contractures greater than 20°¹. It is essential to seek medical advice if there are concerns about an individual's capacity to stand and weight bear before attempting to trial a standing wheelchair¹.

While being aware of clinical research on standing wheelchairs is essential, sometimes the most valuable feedback comes from the individuals who use the equipment themselves:

In standing you can get a real hug; you can look over a crowd and you feel like a human being¹³. 

Whether you're a wheelchair user seeking to trial a standing power wheelchair, or a clinician looking to enhance the wellbeing and function of your clients, our Assistive Technology Consultants possess the knowledge and expertise to address your concerns effectively.

References:

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