Taking a Stand: Overcoming Obstacles to Improve Outcomes

23/02/2021

Thomas Halka, OTR, ATP

Regional Clinical Education Manager Short bio if you’re that interesting.

Continuing Education Approvals

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Continuing Education Credits: 0.1 CEU (1 hour)

AOTA approvals Permobil Academy is an AOTA Approved Provider of professional development. This live lecture is offered at .1 CEUs, Educational level: intermediate; Category: OT Service Delivery. AOTA does not endorse specific course content, products or clinical procedures.

Other PT State approvals The Permobil Academy has also met the criteria for various individual states that do not accept ProCert for PT. Please visit permobilus.com/onsite-events for other state approvals and Permobil Academy completion requirements and cancellation policy.

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Continuing Education Completion Requirements

In order to obtain CEU credits, each participant must complete all 3 criteria Failure to complete each step will result in NO CEUs being awarded

Attend the Entire CourseSign in/Out Complete Course Assessment

https://permobilus.com/academy

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Virtual Continuing Education Completion Requirements

In order to obtain CEU credits, each participant must complete all 3 criteria Failure to complete each step will result in NO CEUs being awarded

Attend the Entire Course Sign-in and Sign-out Complete Course Assessment

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http://bit.ly/Handi022321 ©Permobil

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By the end of the presentation, participants will be able to:

01 03 Discuss the functional basis for standing and why Discuss and justify 3 different ways to provide it’s important standing options for people who are not able to independently stand 02 04 Discuss 3 negative impacts of not standing Discuss 3 different case examples of how using standing wheelchair improves functional status and independence.

http://bit.ly/Handi022321 ©Permobil

Poll Question #1

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Poll Question #2

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Do we have a sitting problem?

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http://bit.ly/Handi022321 What does the Research say?

• More than ½ the people in the US spend most of their waking hours sitting (Mathews et al 2004) • Both the total volume of sedentary time and its accrual in prolonged, uninterrupted bouts are associated with all-cause mortality, (Diaz et al 2017) • Sedentary lifestyle leads to harmful health outcomes (Biwas et al 2015) • “There is reasonable evidence for a likely causal relationship between sedentary behavior and all-cause mortality based on the epidemiological criteria of strength of association, consistency of effect, and temporality.” (Biddle et al 2016)

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People who cannot stand on their own

• 3.6 Million people use wheelchair for mobility in the US (2010 US Census Bureau) • People with SCI have lower energy expenditure at rest Shea, Shay, Leiter, & Cowley (2018). • People burn more energy just by standing (Saeidifard et al 2018)

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People who cannot stand on their own Sales

(Koontz, Ding, Jan, de Groot, & Hansen 2015) ©Permobil Worldwide US UK Canada

Benefits of standing for people with disabilities

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Guiding our Decision

• Body Structures and Function • Long Term prognosis • Endurance/Motor Control • Motivation/learning style • Activities and Participation • Functional abilities • MRADLs/IADLs • Environment • Transportation • Accessibility • Home and Community

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Benefits of standing

(Dicianno., Morgan, Lieberman, & Rosen, 2013) ©Permobil

Improves Breathing

• Body Function and Structure • Respiratory System

• Benefits of Standing • Improved breathing when standing

(Eng et al 2001)

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Improves Breathing

• What about speech???

• Lagier et al (2010) found postural control and positioning had a direct correlation between vocal effort with speaking

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Improves Circulation

• Body Function and Structure • Circulatory system

• Benefits of Standing • Improve circulation when standing results in reduced edema.

(Paleg & Livingstone, 2015)

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Improves Bladder Function

• Body Structure and Function • Urinary system

• Benefits of Standing • Standing reduces incidence and recurrence rate of calculi in the kidneys and bladder • Standing reduces the risk of urinary tract infections

(Eng et al, 2001)

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Improves Bowel Function

• Body Structure and Function • Digestive system

• Benefits of Standing • Standing allows gravity to assist creating natural urge for bowel movement • Standing reduce the incidence of constipation

(Kwok et al 2014)

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Bowel Function

• Standing in a dynamic fashion allows for the stretch of the colon and stimulates bowel movement within the colon. • It is best for a patient to participate a sit to stand motion then to remain stationary in a seated position

(Kwok et al 2014)

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Bone Strength

• Body Structure and Function • Skeletal System

• Benefits of Standing • Maintains bone mineral density • Reduces risk for fractures

(Goktepe, Tugcu, Yilmaz, Alaca, & Gunduz, 2008).

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Bone Strength

• Body Structure and Function • Skeletal System

• Benefits of Standing • Maintains bone mineral density • Reduces risk for fractures

(Dicianno et al 2013)

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ROM and Spasticity

• Body Structure and Function • Musculoskeletal system

• Benefits of Standing • Improves ROM • Reduces spasticity • May Reduce risk of contractures

(Walter et al, 1999)

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Contractures

(Dicianno et al 2013)

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Reduces Risk of Pressure Injury

• Body Structure and Function • Skin integrity

• Benefits of Standing • Body weight loaded on lower extremities • Maximum reduction of pressure from ischial tuberosities

(Sprigle, Maurer, & Sorenblum, 2009)

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Standing Devices

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Standing Devices

Standing Manual Standing Power Standing Frame Wheelchair Wheelchair

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Standing Frame

One Position (E0638) • One Position – prone, supine or upright • May have wheels or be stationary • Primary purpose = upright position

Sit-to-Stand (E0637) • Transitions from sit-stand • Allows for independent transfers

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Standing Frames

Prone Stander Supine Stander

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Standing Frames

Sit-to-Stand Sit-to-Stand

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Standing Manual Wheelchair

• Benefits of Standing • Eliminates need for transfers • Improves standing frequency • Manual wheelchair portability • Quick sit/stand using struts • Active users

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Standing Manual Wheelchair

• Limited standing sequence options • Unable to move when standing • Heavier than ultralight weight manual wheelchairs

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Standing Power Wheelchairs

• Increases independence • Transfer Assist • Stand/sit transitions • Pump versus joystick/switch access • Adjustments while standing • Environmental Access

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Standing Recommendations

• “30 min 5 times a week for positive impact on most outcomes such as self-care and standing balance, ROM, cardio-respiratory, strength, spasticity, pain, skin and bladder and bowel function” • “60 min 4–6 times a week may be required for positive impact on BMD and mental function”

(Paleg &Livingstone, 2015)

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Standing Frame Integrated Standing

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Integrated Standing –Static to Dynamic

Integrated standing Devices

Dynamic Easy Stand/ Wheelchairs

Stationary Static Frames

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Dynamic Standing

Non-ambulatory children with CP (n=9) 4 in passive standers; 5 in dynamic standers Followed for 15 months - 30 minutes/day; 5 days/week Dual energy x-ray absorptiometry scans of the distal femur obtained at 3-month intervals Bone Mineral Density (BMD), Content (BMC), and Area Dynamic standing – increased BMD Passive (static) standing – maintained baseline BMD Both improved BMD (dynamic with greater results)

(Damcott, Blochlinger, & Foulds, 2013)

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Integrated Standing - Benefits

Transfers Standing Independence Duration

Space considerations Programing

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Transfers

• Eliminates need for transfer • Decreases risk of injury • Decreases caregiver assist needed • Decreases • Pain • Spasticity • Anxiety • Time

https://moiramunro.photodeck.com/media/0f3a91f1-8d56-43cc-afc9-c47aec43ab4a-two-nurses-drag-lift- a-patient-up-the-bed-unsafe-lift-moving

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Duration

• Increases ability to stand for longer total time/day • Many sets • Many environments • Home • Work • School

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Independence

• User has more control over when they want to stand • Increases empowerment • Improves adherence to standing program • Independently change position when standing

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Space Considerations

• 2 functions with one device • Wheelchair • Stander

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Programmability

• Stand sequence designed for user • Wheelchair adapts to user • Limitations in ROM • Blood Pressure regulation • Comfort • Control

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Integrated standing

• Caulton et al. (2004) Found that children who stood 60 minutes/day had increased bone mineral density when standing with maximal hip extension and abduction

• Martinsson and Himmelmann (2011) Found that number dropped from 30-60 minutes a day as the child got older

• Nordström, Näslund, Ekenberg, & Zingmark, (2014). Standing time decreased with age and by the time the child transitioned to adulthood they weren’t standing at all.

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The Balance of Standing

Integrated Non-integrated Standing Standing

(Nordstrom et al 2014)

Can I Get my Client Integrated Standing?

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Diagnosis

Neurological Disease Spinal Cord Injury Brain Injury

• Amyotrophic/Primary Lateral • Traumatic • Stroke (CVA) Sclerosis (ALS/PLS) • Non-Traumatic • Cerebral Palsy (CP) • Muscular Dystrophy (MD) • Spinal Bifida • Traumatic (TBI) • Spinal Muscular Atrophy (SMA) • Multiple Sclerosis (MS)

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Who’s Driving the Bus? Diagnosis

Funding

Should diagnosis be driving clinical decision making? Clinical Not Ideally!!! Decisions

Outcomes

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Although the payor source may try to dictate our clinical decision, anyone who is unable to change their body position or stand upright on their own MAY be a candidate for standing.

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Identifying the Correct Client

• Qualifies for Group 3 Power • Participates in standing program • Expresses desire to stand more frequently using wheelchair?

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Cool Metal Thing

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Time-Line

• Consider time needed for trials, documentation, approval and delivery • Be realistic about time needed to 9 months complete the process 6 months

3 months

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Drive Style

• • Can be challenging for client to http://meritcd.com/blogs/wp-content/uploads/2014/04/Decision-Making.jpg change drive style • May be necessary to get appropriate standing power wheelchair

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Drive Style

Least amount of space for L-Turn FWD

Least amount of space for 360 Turn MWD

Best for maneuvering in confined MWD & FWD spaces (Koontz et al, 2010)

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FWD for Maneuverability

“The handling of front-wheel-drive PWCs may be more intuitive for some users because the center of rotation is toward the front of wheelchair, enabling the user to initiate a turn at the bend versus having to judge when to begin initiating a turn in order to accommodate a wider front-end swing angle.”

(Koontz et al, 2010)

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Stability -FWD

Ideal COG & Weight Distribution

Front

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Stability MWD

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Safety

Consider…

• Complexity • Cognition • Driving while standing • Standing accessories

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Seating/Accessory Considerations

Consider

• Postural support required • Contractures/ROM limitations • Aggressive seating components • Communication Devices

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Upper Midwest

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Upper Midwest

• Three-part evaluation process • Involvement of the OT/PT, ATP, and manufacturer’s rep from the first evaluation to the delivery. Patient Home Trial Log trial

Clinical Trial

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Northeast

• Documentation must include • independence going from sit to stand, • duration of usage repetitions for going from sit to stand • Goals for standing established • History of standing program • Trial logs often completed by clinician

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Northeast

• Product comparison-trial of other options for powered standing • Usage of Permobil’s LMN generator

Texas

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Texas

What does that mean for my state?

The Truth…. The process to obtain standing requires a lot on the part of the entire team • The clinician writing more in-depth letters of medical necessity • The supplier may require more time and follow up with funding sources • The client/patient has the wait to obtain their device

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Documentation

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NCART Standing Device Evaluation Worksheet

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Clinical Evaluation/Trial

• Evaluate the patient based on medical necessity and functional need for standing • Focus on the return to independent or semi- independent MRADLs • Require all patient’s fill out a trial standing log • Clinic visits • At home with a caregiver in a loaned stationary standing frame

***More detail from the client/caregivers, the better***

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Establishing Standing Goals

"Clinicians should consult their patients about desired goals and monitor that these results are being achieved through use of qualitative, subjective or self-report in addition to objective assessments." (Paleg et al. 2013)

Establishing Standing Goals

Don’t over think your goals Make them basic and achievable

Establishing Standing Goals

• Patient will stand upright for >= 30 min/day to increase weight bearing for maintained flexibility (ROM) and strength in LE’s, improve circulation and assist with ADL’s

• Patient will stand for upright >= 30 min/day to increase upright positioning needed for optimal bowel/bladder function, digestion, and respiration

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Clinical Support For Standing

Medical Functional

• Bone density • Laundry • Reduction of spasticity • Cooking or meal preparation • Bowel/Bladder management • Utilizing the restroom • Pain reduction/management • Reaching into cupboards etc. • Shoulder preservation • Donning and doffing clothing • Pressure management • Daily cares

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Documentation

Power Standing wheelchair Device

Powered Standing Wheelchair

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Documentation Examples

“A separate standing frame would require additional time and dependence on caregivers, as the patient would not be able to set it up independently, and also does not have the hand/UE function to use the 'pump' to use it independently to get into the upright position. “

***is unable to stand independently. During the trial, however, *** utilized the standing power seat function on the demo PWC safely and independently. The overall fit and integration within the PWC base allows for increased comfort, positioning, adjustability, function, and most importantly medical benefits.

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Documentation Examples

The patient will be able to access the power seat function through the joystick, and they demonstrated independence and safety with this activity as well as donning/doffing the supportive pieces (chest bar/support and knee positioners). A separate standing frame would not only limit the patient’s ability to use the standing feature throughout their home and community, but it would also require an additional transfer, additional PCA time, and personal energy expenditure.

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Documentation

Pictures and Videos of the patient can tell amazing stories

Documentation Resources

• Permobil’s LMN Generator • https://www.permobillmn.com/login • US Funding • [email protected] https://www.ncart.us/uploads/userfiles/files/ncart-standing-device-funding- guide.pdf State Medicaid Director Letters www.cms.hhs.gov https://usdocs.permobil.com/sales/Medicaid_list.php

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Outcome Measures

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What Outcomes??

• Client satisfaction • Therapist satisfaction • Data and Objective measures • Dealer satisfaction

Outcome Measures

WhoM Clinician Activity and 2 versions Administered participation Adult > 18 following the ICF Young person <18 framework FMA Self reporting tool 10 activities of daily Multiple follow up living surveys if needed FEW Self reporting tool Measures client satisfaction within their mobility system QUEST Survey 12 items with a 5 2 subsets including point ranking Assistive device & determining Service delivery satisfaction

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Insurance Coverage

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Coverage Critera

Group 3 Power Mobility Group 4 Power Mobility

• Capable of alternative drive components • Capable of alternative drive components • Drive wheel suspension • Drive wheel suspension • Accommodates seating and positioning • Accommodates seating and positioning devices devices • Accommodates power seat function • Accommodates power seat function • Top Speed 4.5 mph • Top speed: 6 mph • Dynamic Stability Incline 7.5 degrees • Dynamic Stability Incline: 9 degrees

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Federal Coverage Group 3

• The beneficiary requires a drive control interface other than a hand or chin- operated standard proportional joystick (examples include but are not limited to head control, sip and puff, switch control); or • The beneficiary meets coverage criteria for a power tilt or a power recline seating system (see Wheelchair Options and Accessories policy for coverage criteria) and the system is being used on the wheelchair; or • The beneficiary uses a ventilator which is mounted on the wheelchair. • Neuromuscular diagnosis: ALS, MS, SCI, CVA

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Federal Coverage Group 4

• Group 4 : added capabilities that are not necessary for in home usage. • Therefore, these wheelchairs are considered not reasonable or necessary and are denied

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So, What About Other Payors???

Medicaid Private Insurance Alternative Funding

• Coverage varies state • Show documented • ????? to state medical and • Payor of last resort functional need History of pain Functional Limitations Fatigue

Alternative Funding

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Alternative Funding Options

1 5 Local Re-Use programs Social Media/ Go Fund Me

2 Upgrade programs from 6 ABLEnow manufacturers/Demo chair sales

3 Private Pay 7 Help Hope Live

4Care Credit

Alternative Funding Resources https://hub.permobil.com/permobil-resources

Case Examples

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I think this was very important because it has increased my independence and my self esteem.

— Landon Rickley Permobil Power User

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Questions?

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Continuing Education Online Assessment Sign-in / Sign-out Sheet Information All attendees must fill out the sign in sheet http://bit.ly/Handi022321 Online CEU Assessment Failure to complete will result in NO CEU certificate/credit being issued

To take the CEU assessment: http://bit.ly/Handi022321

http://permobilus.com Click on Education

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To take the CEU assessment:

http://bit.ly/Handi022321 http://permobilus.com Click on Education Click on Permobil Academy

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To take the CEU assessment:

http://bit.ly/Handi022321 http://permobilus.com Click on Education Click on Permobil Academy Click on On-Site CEU/CCU Assessments

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To take the CEU assessment:

http://permobilus.com Click on Education Password: Click on Permobil Academy 8a5S4 Click on On-Site CEU/CCU Assessments Click on Take Assessment for today’s Date l Topic St Paul MN 2 week survey deadline from today

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References

• Eng et al., (2001). Use of Prolonged Standing for Individuals With Spinal Cord Injuries. Physical Therapy, 81(8), 1392-1399 • Koontz, A. M., Ding, D., Jan, Y. K., de Groot, S., & Hansen, A. (2015). Wheeled mobility. BioMed research international, 2015, 138176. doi:10.1155/2015/138176 • Nordström, B., Näslund, A., Ekenberg, L., & Zingmark, K. (2014). The ambiguity of standing in standing devices: a qualitative interview study concerning children and parents experiences of the use of standing devices. Physiotherapy theory and practice, 30(7), 483-489. • Paleg, J., 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 Musculoskeletal Disorders, 16:358 DOI 10.1186/s12891-015-0813-x. • Sprigle, S, Maurer, C, & Sorenblum, S. (2010). Load Redistribution in Variable Position Wheelchairs in People With Spinal Cord Injury. The Journal of Spinal Cord Medicine, 33(1), 58-64. • Walter, J, Sola, P, Sacks, J, Lucero, Y, Langbien, E, & Weaver, F. (1999). Indications for a Home Standing Program for Individuals with Spinal Cord Injury, The Journal of Spinal Cord Medicine, 22(3), 52-58. • Goktepe, A. S., Tugcu, I., Yilmaz, B., Alaca, R., & Gunduz, S. (2008). Does standing protect bone density in patients with chronic spinal cord injury?. The journal of spinal cord medicine, 31(2), 197-201. • Kwok, S., Harvey, L., Glinsky, J., Bowden, J. L., Coggrave, M., & Tussler, D. (2015). Does regular standing improve bowel function in people with spinal cord injury? A randomised crossover trial. Spinal cord, 53(1), 36.

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References

• Eng et al., (2001). Use of Prolonged Standing for Individuals With Spinal Cord Injuries. Physical Therapy, 81(8), 1392-1399 • Koontz, A. M., Ding, D., Jan, Y. K., de Groot, S., & Hansen, A. (2015). Wheeled mobility. BioMed research international, 2015, 138176. doi:10.1155/2015/138176 • Nordström, B., Näslund, A., Ekenberg, L., & Zingmark, K. (2014). The ambiguity of standing in standing devices: a qualitative interview study concerning children and parents experiences of the use of standing devices. Physiotherapy theory and practice, 30(7), 483-489. • Paleg, J., 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 Musculoskeletal Disorders, 16:358 DOI 10.1186/s12891-015-0813-x. • Sprigle, S, Maurer, C, & Sorenblum, S. (2010). Load Redistribution in Variable Position Wheelchairs in People With Spinal Cord Injury. The Journal of Spinal Cord Medicine, 33(1), 58-64. • Walter, J, Sola, P, Sacks, J, Lucero, Y, Langbien, E, & Weaver, F. (1999). Indications for a Home Standing Program for Individuals with Spinal Cord Injury, The Journal of Spinal Cord Medicine, 22(3), 52-58. • Dicianno, B. E., Morgan, A., Lieberman, J., & Rosen, L. (2016). Rehabilitation Engineering & Assistive Technology Society (RESNA) position on the application of wheelchair standing devices: 2013 current state of the literature. Assistive Technology, 28(1), 57- 62.

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References

• Damcott, M., Blochlinger, S., & Foulds, R. (2013). Effects of passive versus dynamic loading interventions on bone health in children who are nonambulatory. Pediatric Physical Therapy, 25(3), 248-255. • Caulton, J. M., Ward, K. A., Alsop, C. W., Dunn, G., Adams, J. E., & Mughal, M. Z. (2004). A randomised controlled trial of standing programme on bone mineral density in non-ambulant children with cerebral palsy. Archives of Disease in Childhood, 89(2), 131-135. • Martinsson, C., & Himmelmann, K. (2011). Effect of weight-bearing in abduction and extension on hip stability in children with cerebral palsy. Pediatric Physical Therapy, 23(2), 150-157. • Saeidifard, F., Medina-Inojosa, J. R., Supervia, M., Olson, T. P., Somers, V. K., Erwin, P. J., & Lopez-Jimenez, F. (2018). Differences of energy expenditure while sitting versus standing: A systematic review and meta-analysis. European journal of preventive cardiology, 25(5), 522- 538. • Matthews, C. E., Chen, K. Y., Freedson, P. S., Buchowski, M. S., Beech, B. M., Pate, R. R., & Troiano, R. P. (2008). Amount of time spent in sedentary behaviors in the United States, 2003–2004. American journal of epidemiology, 167(7), 875-881. • Biddle, S. J., Bennie, J. A., Bauman, A. E., Chau, J. Y., Dunstan, D., Owen, N., ... & Van Uffelen, J. G. (2016). Too much sitting and all-cause mortality: is there a causal link?. BMC public health, 16(1), 635. • Diaz, K. M., Howard, V. J., Hutto, B., Colabianchi, N., Vena, J. E., Safford, M. M., ... & Hooker, S. P. (2017). Patterns of sedentary behavior and mortality in US middle-aged and older adults: a national cohort study. Annals of internal medicine, 167(7), 465- 475.

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References

• Biswas, A., Oh, P. I., Faulkner, G. E., Bajaj, R. R., Silver, M. A., Mitchell, M. S., & Alter, D. A. (2015). Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis. Annals of internal medicine, 162(2), 123-132. • Shea, J. R., Shay, B. L., Leiter, J., & Cowley, K. C. (2018). Energy expenditure as a function of activity level after spinal cord injury: the need for tetraplegia-specific energy balance guidelines. Frontiers in physiology, 9, 1286. • Lagier, A., Vaugoyeau, M., Ghio, A., Legou, T., Giovanni, A., & Assaiante, C. (2010). Coordination between posture and phonation in vocal effort behavior. Folia Phoniatrica et Logopaedica, 62(4), 195-202. • Rice, L. A., Yarnot, R., Mills, S., & Sonsoff, J. (2019). A pilot investigation of anterior tilt use among power wheelchair users. Disability and Rehabilitation: Assistive Technology, 1-8.