The Health Benefits of Standing Powerchairs - A Deep Dive
Introduction
Standing powerchairs (also called Powered Wheelchair Standing Devices or PWSD's) are commonly regarded as the pinnacle of powerchairs. Although uncommon here in the UK, including here in Kent, the market for powerchairs that stand is growing quickly. Helpfully, scientific research papers providing measurable and specific data on patient outcomes is also expanding assisting clinicians and prescribers with supporting specific types of disability and desired ADL's. Standing powerchairs are more expensive than powerchairs that do not have the standing function, often in the order of 50-100% more. However, as the volume of production increases, and the real world value of the standing function is better understood, there is scope for greater competition and inevitably enhanced access via state funded routes such as the NHS and Motability1.
This Deep Dive aims to unravel some of the mystery that surrounds standing powerchairs by combining our own professional experience, evidence from the latest published research, and information from two of the leading standing powerchair manufacturers in the world - Sunrise Medical and Permobil. We will explore different topics including:
- What is a standing chair?
- The powered wheelbase
- The standing functions
- What are the benefits of a standing chair?
- Clinical benefits
- Functional benefits
- Psychosocial benefits
- How can you get a standing chair?
- The assessment
- Motability
- The NHS
- Charitable Support
- Private Funding
What is a standing powerchair?
It is imperative that different terms are used correctly when defining a product or system to make the sharing of best practice and information easy and relatable. A standing powerchair combines years of development from two paradigms - that of powerchair technology and standing device technology. Their culmination is what we refer to as a standing powerchair - the ability for someone to raise themselves from a seated position to a standing position via a powerchair.
This is captured within the definition of standing powerchairs from a white paper published by Permobil which defines it as:
'Power standing is defined as a system that encompasses the ability for a standing system (consistent of multiple actuators and power seat functions such as tilt, recline, elevating legs, and seat elevate) to be utilized in its full capacity upon a power wheelchair base. This combination of seat functions and power base allow the user to optimally achieve both a seated and standing position within the system, while enabling the user to access his/her environment with the use of mobility.'2
Easy to overlook the ability to stand is something able bodied people often take for granted. 'In standing the whole body must be balanced and stabilized in correct alignment... by the coordinated work of many muscle groups. It is the most difficult of positions.'3 Achieving standing from a sitting position requires most muscles in the body to activate and a moderate degree of muscle tone to perform it in a controlled manner. It is no surprise that aids to standing have existed for centuries to help those with reduced strength convert their position from sitting to standing.
A standing powerchair, when correctly prescribed, can manage the change of position from sitting (or even lying) to standing in a safe, ergonomically-friendly and comfortable way. It achieves this via a combination of electronic actuator-driven seat functions working in tandem to perform this smoothly and safely. The actuators are all individually programmable enabling the chair to be precisely tailored to each individual depending on their disability and physical presentation.
The Powered Wheelbase
Powerchairs, or powered wheelchairs, have developed significantly over the last decade alone. Advances in microprocessor and sensor technology, along with developments in manufacturing techniques and access to new materials has enabled leading manufacturers to produce powerchairs that can do more than ever before. Focusing specifically on the powerbase, powered wheelchairs tend to be divided up into three categories - front-wheel drive, mid-wheel drive and rear-wheel drive. As the name suggests the most striking difference between the chairs is the location of their powered wheels, or drive wheels.
For the purposes of this Deep Dive, it is not important to go too deep into which configuration offers what benefits. It is however worth considering why different types exist at all. The three categories exist because each has its own merits and affords the occupant different benefits. Front-wheel drive powerchairs are known for being the least intuitive but make up for it in terms of outdoor performance and their ability to climb. Conversely, rear-wheel drive powerchairs are often seen as the quickest to learn to drive - the most intuitive - but they typically have large turning circles and are hard to manoeuvre precisely. Midwheel drive powerchairs are perhaps the easiest to steer but their outdoor performance is affected by the presence of castors front and rear and they usually cost more than the equivalent rear-wheel variant.
Considering the ability of each powerbase to manage specific environments and needs is a great starting point when approaching a complex powerchair such as the standing powerchair range. The role of the powerbase is to provide a robust, dependable, and effective platform onto which is mounted a seating system capable of seating an occupant safely and comfortably for extended periods. This powerbase therefore must be able to perform in challenging conditions, for prolonged periods of time and perform the role of the legs/ feet in an able-bodied person.
The goal of most people who require powerchairs is to be able to go and do what they aspire to do. Understanding these precise goals, aspirations and wants is crucial to a prescriber or clinician when effectively designing a bespoke product. Standing powerchairs from the leading manufacturers are only available with mid-wheel drive and front-wheel drive configurations. Which will provide the best outcome is a conversation that must be had, and then an experience that should be felt, before any conclusive decisions are made.
The powerbase has its own section here in this Deep Dive because it can be overlooked, to the detriment of the user. It is imperative to remember that the powerbase is the sole interface between the ground and the seating system and is the housing for the systems and mechanical components to provide motion and altered positioning. When talking about complex and often abstract theories to new powerchair users it can be helpful to outline what a bad powerchair looks like. An inferior powerbase is one that is unreliable, unstable, hard to drive, difficult to repair and unable to achieve the identified goals. It is also expensive to maintain, has a shorter or less inclusive warranty than is typically found, is sold without robust aftercare, and can represent very poor value for money and even, at the extreme, a hazard to health.
The Standing Functions
The standing functions relate specifically to the mechanisms by which standing from a seated position is achieved. This is explained separately to the powered wheelbase because it demands an entirely different suite of skills and resources on the part of the prescriber to get right. It is also the aspect of any powered wheelchair assessment that takes the longest and is the most critical to providing a safe upright posture. Achieving a standing position requires the combined work of different electronic actuators and a clinically appropriate seating system (also known as postural support devices, or informally, cushions). The seating system refers to any part of the chair that interacts with the body either constantly or intermittently to support the weight of the body while managing inherent risks from shearing, moisture build-up, elevated pressure, and postural stability. Given the number of moving parts and the extremes of angles needed to accommodate a vertical stand the seating system is arguably the single most important aspect to configure correctly.
The seating systems on the two leading manufacturers of standing powerchairs, Sunrise Medical and Permobil, are called Sedeo Ergo and Corpus Seating, respectively. These systems include every aspect involved in seating, lying, or standing including the legrests, calf supports, knee supports, base cushion, backrest support, armrests, chest support, headrest and much more. This seating must be able to support the occupant in every possible position which can include lying (supine), semi-reclined, in tilt and then in the various stages of upright standing. Stop the actuators at any point in their movement(s) and the seating system must still be able to manage all the previously identified risks and postural needs. For this reason alone, standing powerchairs tend to be equipped with the most modular and clinically capable support surfaces on the market.
Just like in non-standing powerchairs the seating must accommodate and manage the physical presentation of the person using the chair. Standing powerchairs are designed to accommodate various obliquities, rotations, pressure injuries, reduced functions and muscle tone, scoliosis' and kyphosis' and many specific medical conditions. For advice on whether a seating system will be able to accommodate your specific needs will require a consultation with an expert. If you are based in Kent or on the borders of Kent and would like a free consultation, please use the referral form at the top of the page to get in touch.
What are the benefits of a standing chair?
There are numerous benefits to be had from achieving a standing position while still being able to mobilise independently. These benefits can be broken down into categories such as clinical, functional, and psychosocial. This article is not able to touch on every single available benefit as each standing powerchair user will have their own specific personal ways they believe their life has been enhanced. We will however look at the major classes and explore at a surface level how they increase the utility, outcomes, and quality of life.
Clinical Benefits of Standing Chairs
A clinical benefit is defined by the Medical Dictionary as the 'Prolongation of life, reduction in pain, improvement in function [or] increased sense of well-being.'4 Clinical benefits are therefore anything advantageous that can be gained from an intervention such as a powerchair that can stand. For the purposes of this article, we will not be looking at the more broad advantages that are experienced from owning a powerchair, or from being able to stand in isolation to one another.
For any intervention with anticipated measurable outcomes, it is important to consider the 'do nothing' case, which details the baseline outcomes if no intervention was made. This serves as a comparison to any effects that are noticed following a change. In this case the 'do nothing' or comparison situation is to look at the problems associated with prolonged sitting and compare these with the benefits or problems associated with standing.
The problems linked to prolonged periods of sitting are increasingly well known amongst the population. The NHS recommends we exercise regularly for at least 150 minutes a week and to reduce sitting time by standing frequently. Long periods of sitting are thought to slow the metabolism which has lasting effects on the body's ability to regulate its blood sugar levels, blood pressure and the breakdown of fat. It is therefore linked to an increased risk of heart and circulatory complications in later life. The act of standing itself is classed as light mobility, and remaining standing offers benefits that go beyond the obvious cardiovascular ones.
Let us quickly look at some of the main clinical benefits:
1) Increased Bone Density
Studies have shown that bearing weight through our bones helps prevent the loss of bone density typically seen as we age and/ or become inactive. Weight-bearing along with good nutrition helps our bones stay stronger for longer. In some situations, this may enable a person who requires the use of a powerchair for most situations to continue performing those activities currently performed without the need for a powerchair.
2) Improved Circulation
Standing, and the act of rising from a seated to a standing position, infers numerous benefits to the circulatory system in the body. Sitting can reduce the circulation of blood in the body which can lead to swelling or even clotting. Standing offloads pressure from the bottom and back which enables the blood vessels sited here to refill and the skin to recover.
3) Improved breathing and speech
Taking a very deep breath when seated is much harder work when seated compared to standing. This is because the room in which the diaphragm and lungs have to expand into is improved when stood up (or lying down). Being able to breathe more easily can improve blood oxygen levels, the ability to clear mucus through coughing and speech.
4) Improved skin health
As seen in point 2 above there are benefits to the health of the largest organ in the body - the skin. Any part of the body that we sit on can become damaged through prolonged sitting. The most at-risk areas are on the bottom and are found on the bony prominences called the ischial tuberosities. This is the most common area for pressure related damage to form on the body and one of the greatest risk factors is the length of time sat static followed by the type of surface someone is sat on. Standing via a powerchair that is correctly configured will be achieved without shear forces acting on the skin and will give these at-risk areas a chance to recover and dry.
5) Improved bowel function
Improved digestion is one outcome that many studies have shown can be attributed to the act of standing. It is thought the improvements to digestion are because of the colon being stretched stimulating bowel movements. Similarly other studies have shown that food progresses from the stomach to the intestines most actively when the body's position is being changed, as opposed to when remaining in a single position.
6) Improved bladder management
Like the above point there are benefits to the way the bladder functions too. Studies have shown that improved bladder control i.e. the ability to retain fluids and release them on command can improve or be regained if lost through standing regularly.
7) Range of motion and muscle length
People that rely on the use of wheelchairs and powerchairs typically lose some range of movement and muscle length through time. This shortening of the muscles prevents a joint being able to move through its normal range of movement, inhibiting the body to achieve a certain function. This action is referred to as a contracture. Standing powerchairs have been shown to improve or maintain range of motion in children and adults although it is dependent to some extent on the nature of the disability and how soon the standing function is introduced following diagnosis.
Functional Benefits of Standing Chairs
Functional benefits of any product or device refer to the ability to perform a task or function that would have otherwise been impossible or more difficult without the product or device to assist. When considering the benefits of standing powerchairs it is easy to think of a few functional benefits - the most obvious being the ability to reach objects that are high up. Accessing items from shelves in a supermarket or from a cupboard at home is the most commonly known benefit of a standing chair. While correct of course this often-repeated single advantage can serve to nullify both the exceptional gain this single benefit derives, but also to limit understanding of the other less known benefits.
Other functional opportunities that standing opportunities provide include (but are certainly not limited to):
- Easier conversations with able bodied people with significant benefits for various social interactions especially at school or in the workplace
- The ability to perform household chores such as doing the washing up
- Accessing information screens, payment terminals and checkouts or banking windows
- Enhanced views over ledges, walls, or other obstacles
- Easier to order food at mobile food outlets or get information from kiosks
- For long spinal cord injuries the ability to partake in some outdoor games
- Ability to clean hard to reach places
- Looking out of windows
- Exercising
- Working within an office environment or manufacturing environment
- Improved hearing and ability to lip read if required
- Improved personal hygiene such as washing hands
The design of living and workspaces in the United Kingdom assumes that the person using the workspace can stand. What this means in practice is that cupboards are either high up, or low down - very few are at the height a person using a wheelchair may be able to access. This same logic applies to the position of the handles, light switches, taps and toilet flushes, or to many white goods and their typical locations within the kitchen or utility room. Powered standing allows someone to access a wider range of unmodified spaces in the house without making any structural or interior alterations. This is one argument when considering the cost and value of a power chair that should be considered as it can sometimes negate the need for expensive reconstruction.
All these benefits mentioned thus far are primary benefits - that is, benefits that are immediately received because of standing. The lesser seen benefits are the secondary ones which include the clinical and psychosocial benefits which we will look at next.
The Psychosocial Benefits of Standing Chairs
The definition of psychosocial according to the Oxford English Dictionary is 'the interrelation of social factors and individual thought and behaviour.' One of the most recognised disorders resulting from environments that offer poor psychosocial benefits is that of mental health disorders. Studies have shown that there is a strong correlation between people diagnosed with spinal cord injury and depression along with other mental health problems.
Reams of testimony pertain to the difficulties faced by people with a disability in the UK and across the world. Inequalities abound and barriers that limit the experiences, opportunities and quality of life other able-bodied people enjoy are found in every facet of life. Environments must be accessible, and the culture must be one of embracement for those with disabilities, whether seen or unseen. This culture should extend right across the spectrum, from early childhood through to old age, in schools, workplaces and public spaces such as museums, cinemas and theme parks. When someone is unable to access a space because of something as simple as a kerb, or a workspace that is too high the effects on esteem can be devastating. When this frustration is felt multiple times a day the impact on mental health can be abrupt and severe - happiness, self-esteem, quality of life and the sense of well-being are all likely to suffer.
The benefits of standing therefore go well beyond the measurable benefits as found in the clinical benefits section and extent to the qualitative - feeling happier, feeling more involved, feeling better respected etc. It is easy to overlook these benefits when considering this type of equipment, but the potential benefits are so strong the best way to find out is to try. If you would like to trial a standing powerchair locate your nearest specialist who is able to provide a free assessment and who gives you the appropriate time and space to ask questions freely and voice any concerns you may have. If you are located in Kent or the South East corner of England, please submit our referral form above and we can begin the journey together.
How do you get a standing chair?
There are numerous routes available to anyone interested in a standing powerchair. Unlike non-prescription and basic powerchairs which are available at most dealerships across the UK only the dealerships with the clinical expertise and technical after-care support on hand can complete standing powerchair assessments. At Cinque Ports Healthcare we are one of only a handful of regional dealers able to provide standing chair assessments - which we do free of charge an in accordance with a high standard of ethics and social responsibility.
The two standing chairs we currently support are the Sunrise Medical Q700 Up and the Permobil F5 VS (Vertical Stand). These powerchairs have exceed the benchmark we have set as a company in terms of design quality, longevity, aftercare support from the manufactures, lead times on spares and most importantly clinical capability. We are aware of a number of dramatically inferior powerchairs on the market, some which are imported without UK based support, and advise strongly against these. Small savings in the back pocket amount to little when things go wrong, or when you experience the negative effects of an improperly prescribed system. So, what does a good assessment entail and how do you know when you have been given an appropriate solution?
The Assessment
All prescriptive powerchairs are sold (we prefer 'prescribed') via assessment. Sometimes, and especially with standing powerchairs, it is likely more than one assessment may be needed. The purpose of the assessment is for us, the clinicians and experts, to:
- Identify and record as best we can your anatomical structures and how they present when sitting (and if needed, lying, and standing)
- Learn about your medical history and discuss how your disability affects your every day
- Recognise and champion your personal goals and wishes while being honest and realistic
- Present the powerchair and its functions with integrity and entirely void of any sales nonsense
- Give you the opportunity to experience the powerchair and standing, not just read about it
- Give you time and space when you need it, and all the tools and information you may need to make an informed decision.
If you have an assessment with a provider who is unable to achieve the above points, or a dealership who apply a form of pressure tactic to encourage you to buy, move on. This type of equipment is immensely complex and is at the top end of the spectrum of non-regulated medical equipment and at this level there is no place for mismanaged expectations or obligations to buy without proper consideration.
Before getting to the assessment however you may be wondering how you are going to fund the cost of the powerchair. Read on for information about the different routes available. If you are within Kent or the South East corner of England please feel free to contact us so we can support you with your own case.
Motability
The Motability Scheme is a national government-backed scheme which enables you to convert any qualifying mobility benefit to lease a new powerchair. This can be over the period of 3 or 5 years and throughout the duration of the lease you will only ever pay a single weekly amount which will never exceed your total benefit.
One of the greatest aspects of the Motability Scheme is the benefits it gives you which Motability call their worry-free package... and it truly is worry free. For starters only certain dealerships are approved to support users on Motability contracts. These dealers are all regulated by the FCA, BHTA and Motability themselves to ensure a continued high standard of care pre-assessment and throughout the term of the lease. Secondly the single weekly payment covers all aspects of the ongoing maintenance and warranty problems that may arise during the 3 or 5 year term. Batteries and tyres, for example, are two of the most common expenditures needed. Privately a set of 6 tyres for a midwheel drive powerchair and a pair of batteries could cost close to £600 but on Motability these are included. Similarly, sometimes accidents happen which, without insurance, can be costly. A broken castor arm or suspension assembly can cost hundreds in parts and labour to repair and replace but with Motability's all-inclusive insurance these are covered with no premiums to pay. It is genuinely worry free and one of the best 'deals' going as far as we are concerned.
This post is not designed to explore all the benefits, and some of the possible downsides, to the scheme but if you are unsure and want to discuss it with us please drop us an email or pick up the phone. This post is however meant to help you work out whether the scheme can support you with accessing a standing powerchair. If you have a qualifying benefit, such as the higher rate of mobility component of the personal independence payment (PIP) or the higher rate award of the disability living allowance (DLA) it is quite likely you are eligible.
Given the cost of the standing powerchair it is not possible even on a five-year agreement to cover the entire cost of the chair without an upfront deposit. The exact deposit will depend on the precise specification you agree on but it is likely to be several thousand pounds. The good news is there are other ways to raise this deposit, or to fully fund a chair privately.
The NHS Wheelchair Voucher Scheme
The NHS Wheelchair Services in Kent is run by Millbrook Healthcare - a private company who manage the NHS Contract on behalf of the NHS. Millbrook Healthcare are contracted to provide a wheelchair or powerchair to anyone who meets the eligibility criteria. Once the therapists have assessed for eligibility the type of powerchair available will be discussed. At the time of writing the most common high-end powerchair provided by Millbrook is the Sunrise Medical Q300M although others are available on the equipment matrix.
If you are seeking a standing powerchair such as the Sunrise Q700 UP or the Permobil F5 VS you will need to ask to proceed down the Voucher Scheme route. On this pathway the cost of the recommended provision at NHS prices will be converted to a voucher which can then be applied to any qualifying equipment purchased from a third party approved supplier. Cinque Ports Healthcare are an approved supplier to the NHS, and we work closely with Millbrook to ensure only the most appropriate equipment is prescribed. For more information about the wheelchair voucher scheme please click here.
The exact amount you are awarded via the voucher scheme will be dependent on the powered options you were assessed as requiring. Although the voucher amount will always leave you with a shortfall when buying privately the benefits are that you can choose your own equipment and have it maintained and serviced privately. Furthermore, it will belong to you and as such have a greater ability to choose how it looks or functions to suit your own personal tastes or lifestyle.
If you have an NHS Voucher and would like to discuss a standing powerchair assessment or are considering approaching Millbrook with a view to obtaining a voucher, please get in touch and we will assist you through the process as best we can.
Although the amounts vary considerably if you combined the NHS Voucher with the five-year lease option on Motability the size of the deposit will begin to become more manageable, especially if a grant or charitable funding can be used to cover the remainder.
Charitable Support
A number of charities exist that are happy to support with equipment provision. Many are unlikely to cover the full amount but quite often multiple charities will happily work together to raise the total. Depending on the nature of your disability there may be specific charities more able to provide financial support.
Here is a list of Kent-based and National charities that offer support for specific disabilities or for any disability:
If you require assistance with an application or would like summary reports written to support an application please get in touch.
Private Funding
The fourth option is to purchase equipment privately either paying as a lump sum or spreading the cost. As a company we can help support you by spreading the cost over one year with no interest applied. We are also in discussion with various companies looking at how we can help you split the cost over a much longer time period - up to three years potentially - without you being charged high interest rates.
When privately funding equipment it is also important to consider the ongoing maintenance and care costs. Routine maintenance will be on aspects such as batteries and tyres plus annual servicing and ad-hoc inspections or alterations. We do not currently offer care plans that are all inclusive, but we are in discussion with a provider to look at how cost effective these are for you.
If an accident occurs the cost of repairing the damage can be expensive. One of the simplest ways to reduce this cost is to take out an insurance policy. Our preferred provider is Lockton Mobility who can not only provide accidental damage cover but also third party liability cover and protection from fire and theft.
If you have any questions about insuring your product or would like to discuss the typical in-life costs, please get in touch.
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