Funding Guide to Standing Technology (complete 7th Ed.)

Funding Guide to Standing Technology (complete 7th Ed.)
seventh edition
Supporting
Articles
™
•
Research
References Summary
seventh edition
Standing technology should only be used under the guidance of a physician with recommendations for standing program protocol and any
medical precautions. Standing programs should be monitored by the attending therapist. AMI maintains a policy of continual product
improvement and reserves the right to change features, specifications, and prices without prior notification. Check with AMI for latest info.
FORM LMN 0907 Copyright © 2007 Altimate Medical, Inc. All rights reserved. Printed in the U.S.A.
Compliments of Altimate Medical, Inc.
The makers of EasyStand products
Legal Services &
Resources
™
Altimate Medical
This book is also available in
downloadable format at
www.easystand.com
Funding Hotline: 877.844.1172
Phone: 800.342.8968 or 507.697.6393
Fax: 877.342.8968 or 507.697.6900
email: [email protected]
www.easystand.com
Research Studies
•
P.O. Box 180
262 West 1st St
Morton, MN 56270, USA
Letter of
Medical Necessity
Funding Guide for Standing Technology
Funding Guide for
Standing Technology
Dear Friends,
It is our goal at Altimate Medical to provide medical technology that truly improves the quality of life
for our customers.
Our dedicated staff is here to assist you to achieve your goal of a standing program.
EasyStand products are designed by our team of creative engineers who continue to listen to clinical and
consumer feedback as the foundation for solutions to your standing/weight bearing needs.
®
We encourage you to stand for your health and thank you for considering EasyStand standing technology.
Sincerely,
Nancy Perlich, COTA, ATS
Funding Specialist
Funding Hotline 877.844.1172
(CST)
The Funding Guide to Standing Technology is meant to assist you with the process of assessment, written letter of
Medical Necessity (LMN), and the appeals process for standing technology.
The Funding Guide for Standing Technology was published in-house by the staff of Altimate Medical, the makers of
®
EasyStand standing products.
For up to date funding information visit www.easystand.com/funding
For information on our “Standing 101” seminars visit www.easystand.com/smart
www.easystand.com
Table of Contents
Funding Guide for Standing Technology
Letter of Medical Necessity
The Steps to Obtaining a Stander
9 Tips for Achieving Effective Documentation
Team Process
Standing Technology Intake Evaluation
Letter of Medical Necessity Outline
Sample Letters of Medical Necessity
Range of Motion Measurement Table
Supporting Articles
Stand Up for Your Patients
To Stand or Not to Stand
Universal Problems: Denials and Appeals-and Strategies that Work
Taking a Stand
Standing Tall
Creative Solutions-Securing Funding for Post-Adolescents
Getting Up Goals
Defining Medical Necessity
The Physiological Aspects of Immobilization & Beneficial Effects
of Passive Standing
Research Studies
Abstracts
Research References Summary
Research References
Legal Services & Resources
The Consumer’s Appeal Process
PAAT & AT Project Directory
Helpful Websites
Quick Fit Guide
Coding for Standing Technology
1
2
3
5
11
13
21
23
25
28
30
35
40
42
45
47
51
67
79
80
93
94
95
Letter of
Medical Necessity
Letter of
Medical Necessity
The Steps to Obtaining a Stander
The process for obtaining any standing technology is very similar (if not identical) to obtaining
a wheelchair or other piece of Rehab DME (Durable Medical Equipment).
Step 1: Always start by getting approval from your physician. Make sure that it is
medically safe for you to stand.
Letter of
Medical Necessity
Standing Technology
Step 2: Locate a local medical equipment supplier from whom to purchase an EasyStand
stander. If you don’t have a supplier that you have previously worked with to get other
durable medical equipment (DME), please visit www.easystand.com/supplier-locator and
we will assist you in finding a qualified EasyStand supplier near you.
Step 3: Trial the standing equipment. Gather your team (therapist, supplier, caregiver &
yourself) and make arrangements with your local supplier or EasyStand rep to try the
standing equipment first. Your therapist, supplier, or rep may help arrange this.
• If you are seeking funding through private or public payers, your therapist will
document the trial process. This documentation is important as it will be needed
for justification to your payers.
• If you are paying for the stander yourself, place an order with your supplier after
your product trial. Your supplier will then deliver and set up the stander for you.
Step 4: Normally, your therapist will write the letter of medical necessity/justification
including the trial process, with the physician co-signing the letter. Currently most medical
insurance companies cover standing as long as justification is medically specific to the needs
of the individual and not just a list of standing /weight bearing benefits for everyone as a
whole. For better results, the initial letter should be clear and concise to avoid having to
write second or third letters.
Step 5: The letter is then given to your supplier, who will submit it for prior authorization
from your funding sources.
Step 6: If your prior authorization is denied, you have the right to appeal the denial. We offer
resources that may assist you through the appeal process and/or offer alternative funding sources
(see Legal Services and Resources in the back of Funding Guide). Remember a denial is not a
brick wall, just a road block. Many standers have been paid for after one or more appeals.
Step 7: Once your funding is approved the stander is ordered. It will be assembled, delivered
and fitted just for you by your supplier.
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Altimate Medical, Inc. - makers of EasyStand products ©2007
9 Tips for Achieving Effective Documentation
Standing Technology
1. Detail the client: Who is this person medically, functionally, and socially.
2. Explain how the stander will help achieve functional goals/outcomes.
3. Describe trial use of the proposed stander.
4. List alternatives that were considered & rejected. Both least costly and most costly.
5. Provide the client's history of standing compliance.
6. If needed, present photos & videos to convey the information along with written documentation.
7. Be complete, but concise: reviewers do not have time to read a novel.
8. Include supporting material: clinical studies, papers and a resource list.
9. Re-submit and appeal when necessary.
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Altimate Medical, Inc. - makers of EasyStand products ©2007
Team Process
Standing Technology
The members of your team consist of the Rehab Technology Supplier, clinician(s), consumer,
and maybe a caregiver:
Rehab Technology Supplier
Your Rehab/DME Supplier (ATS, ATP, CRTS) specializes in rehab technology, helping you to find
the most appropriate enabling technology to meet your needs. They may also be a member of
one or more of these organizations: NRRTS, RESNA, TXRPC, NEMED, NCART, AAHomecare, or
other regional associations.
Their role and/or responsibilities can include:
• Providing trial equipment or scheduling with local manufacturer’s rep to trial
equipment.
• Having expertise on standing equipment and the options that are available.
• Getting prior authorization with insurance company or your payer source.
• Providing assembly, delivery and adjustments to individual fit.
• Assisting with the appeal process if necessary.
• Being a valuable resource for a wealth of information.
Clinician
Clinicians on your team can consist of one or more of the following members that may have an
emphasis in (AT) Assistive Technology: Physician, (OT) Occupational Therapist, (PT) Physical
Therapist, Speech Therapist, Special Education Teacher, etc.
Their role and/or responsibilities can include:
•
•
•
•
•
Physician must approve that it is medically safe for you to stand.
PT/OT may recommend weight bearing/standing device and program.
PT/OT may review product options and make recommendations.
PT/OT usually writes the letter of medical necessity including trial process.
Physician usually co-signs the therapist’s letter of medical necessity or writes an
additional prescription.
• PT/OT usually attends and assists in the final fit and adjustment of product
• If payer source denies standing device, PT/OT and/or Physician may write addendum
or new letter of medical necessity and/or attend appeals hearing (via teleconference, in
person, or recorded testimony).
• PT/OT may monitor the client’s ongoing standing program.
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Altimate Medical, Inc. - makers of EasyStand products ©2007
Team Process
Letter of
Medical Necessity
Standing Technology
Consumer
The consumer needs to be their own advocate in order to get the equipment that they need and
to protect their medical rights.
The consumer is the person (early intervention through elderly, with various disabilities) who
could benefit from a standing/weight bearing program and is the leader of this process.
Their role and/or responsibilities can include:
•
•
•
•
•
•
•
•
Researching the benefits of standing.
Being aware of their medical need to stand.
Choosing their rehab technology supplier.
Specifying wants and needs in standing equipment.
Trialing and determining the standing equipment.
Following up on progress of this process through its conclusion.
Being present for the final fit.
If an appeal is necessary, the consumer or legal guardian must start the appeals process
(often they are the only person who can start the appeals process).
• Once equipment is received and fitted, the consumer must follow through on their
standing program to receive the outcomes expected.
See the back of this Funding Guide for a list of helpful websites.
Caregiver/Family
The parent, legal guardian, or caregiver of the consumer may be the leader of this process if the
consumer is unable.
Their role and/or responsibilities can include:
• Handling the role of the consumer if they are unable or under 21.
• Providing support and feedback to the team on transfer techniques and activities of
daily living.
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Altimate Medical, Inc. - makers of EasyStand products ©2007
Standing Technology Intake Evaluation
I Client Profile
Client Information
Name:
Address:
City, state, zip:
Home phone:
Work phone:
Social security #:
Date of birth:
Parent/Guardian
Name:
Address: city, state, zip:
Home phone:
Work phone:
Primary Funding Source
Name:
ID #:
Group #:
Claims phone:
Case manager:
Secondary Funding Source
Name:
ID #:
Group #:
Claims phone:
Case manager:
Client's Employment/School Information
Employer/school:
Address:
City, state, zip:
Title/Grade:
Supervisor/educator:
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Altimate Medical, Inc. - makers of EasyStand products ©2007
II General Physical Status
Diagnosis:
Sex:
Height:
Weight:
Onset of disability:
Medical history:
Current Function:
Ambulation: None Limited
Mild assist
Moderate assist
Letter of
Medical Necessity
Standing Technology Intake Evaluation
Wheelchair for mobility - Distance
Maximum assist
Transfer: Independent
Dependent Assist - 1 person 2 person
Method
Activities of daily living: Independent
Partial assist Dependent
Living environment: Home Apartment Institution Single level Multi-level Owns Rents
Current stander / when obtained:
Current standing program:
OT Speech Other
Therapies: PT
Transportation: Car
Van Public transportation Other
Cognitive level: Prereadiness
Readiness On age Level Understands safety of self & others
Comments
Physical Exam:
Fair-hands free only
Sitting Balance: Good - hands free capability to weight shift
Poor-propped & hand support Dependent-needs external support
Muscle Strength: U/E
Normal
Reduced
None
L/E
Normal
Reduced
None
Sitting Posture:
Posterior pelvic tilt
None Fixed Flexible Other
Anterior pelvic tilt
None Fixed Flexible Other
Pelvic Obliquity
None Fixed Flexible Other
Kyphosis
None Fixed Flexible Other
Lordosis
None Fixed Flexible Other
Scoliosis
None Fixed Flexible Other
Head/neck hyperextension
None Fixed Flexible Other
Leg abduction
None Fixed Flexible Other
Leg adduction
None Fixed Flexible Other
Wind sweeping
None Fixed Flexible Other
Other
None Fixed Flexible Other
Tonal influences / reflexes in sitting:
Extensor Flexor ATNR STNR Positive support Ankle clonus Other
Lower extremity range of motion seated:
Hip flexion (normal 0˚ to 125˚)
Knee extension hip at 90˚
Ankle
Other
Skin integrity: Intact Red area Open area Scar tissue History of sores
Area: Ischial tuberosities Coccyx Spine Other
Sensation: Normal Impaired Non-sensate Level
Bowel: Continent Incontinent Training
Bladder: Continent Incontinent Training Other/comments
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Standing Technology Intake Evaluation
III Measurements in Sitting & Standing
1. Seat surface (the contact point of the buttocks) to:
a. PSIS
b. Elbows
c. Inferior angles of scapula
d. Armpit
e. Top of shoulder
f. Top of head
2. Trunk depth (back surface to front of the ribs)
3. Leg length (from where the hips touch backrest
to popliteal angle of knee)
4. Back of knee to heel (or weight-bearing area)
5. Foot length (with shoes & AFO’s if applicable)
6. Trunk width (across chest)
7. Shoulder width
8. Hip width
9. Outer knee width (relaxed, with knees apart)
Left
Right
Standing
7.
6.
1f.
1e.
1d.
1c.
2.
8.
1b.
1a.
3.
9.
4.
5.
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Altimate Medical, Inc. - makers of EasyStand products ©2007
Standing Technology Intake Evaluation
1. Trial date:
Stander style:
Stander mfg.:
Outcome:
2. Trial date:
Stander style:
Stander mfg.:
Outcome:
3. Trial date:
Stander style:
Stander mfg.:
Outcome:
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Altimate Medical, Inc. - makers of EasyStand products ©2007
Letter of
Medical Necessity
IV Equipment Considerations / Trials & Outcomes
Standing Technology Intake Evaluation
V Standing Equipment Needed
Type of stander needed:
Brand name:
Model #:
Special considerations of chosen standing equipment (justification of accessories)
1. Is the patient able to operate that stander independently? YES NO
2. Does the patient use a wheelchair for mobility? YES NO
3. Does the stander have adequate supports, anteriorly, posteriorly, and laterally to position the
person in a symmetrical aligned standing? YES NO
4. Does the stander have enough adjustment to allow for individual fit and allow for growth
changes? YES NO
5. What is the height range and weight capacity of the stander?
From
to
weight capacity
6. Is it relatively easy to modify to meet the individuals position needs? YES NO
7. What are the environmental factors to consider (ie: room size in residence; or if a mobile
stander is it easy to move on existing flooring)?
8. Transfer considerations/caregiver constraints. What makes the model chosen advantageous
in changing positions?
9. Other:
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Altimate Medical, Inc. - makers of EasyStand products ©2007
VI Reasons for Standing Equipment
Letter of
Medical Necessity
Standing Technology Intake Evaluation
____________needs a stander as an adjunct to therapy on a daily basis for the following reasons:
1 Aid in the prevention of atrophy in the trunk and leg muscles YES NO
2 Improve circulation to trunk and lower extremities YES NO
3 Prevent formation of decubiti (pressure sores) through changing positions YES NO
4 Help maintain bone integrity YES NO
5 Improve bowel function and regularity YES NO
6 Reduce swelling in lower extremities YES NO
7 Improve range of motion YES NO
8 Aid kidney and bladder functions YES NO
9 Decrease muscle spasms YES NO
10 Strengthen cardiovascular system and build endurance YES NO
11 Improve strength to trunk and lower extremities. YES NO
12 Prevent or decrease joint/muscle contractures YES NO
13 Lessen or prevent the progression of scoliosis YES NO
14 Aid normal skeletal development YES NO
Please describe in detail the current problems and associated costs this client may be having
due to the absence of a standing program:
Standing program recommendations:
Completed by:
Title:
Facility:
Address:
Date:
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Altimate Medical, Inc. - makers of EasyStand products ©2007
Letter of Medical Necessity Outline
I
Standing Technology
Client:
Date of birth:
Diagnosis:
Onset:
Height:
Weight:
Primary funding:
Brief medical history:
II
Current function:
This area should be a brief but complete description of your client:
• Ambulation: type and how much assist
• Transfers: type and how much assist
• Activities of daily living: how independent or dependent
• Living environment (brief description)
• Mobility: home and community (brief description)
• School/employment (brief description)
III
• Transportation: how (ie: own car, van, public transportation)
Physical/medical condition:
Concentrate on client specific medical overview. Medical issues that will be affected by assistive standing technology and how they will change, for example:
• Posture
• Body muscle control
• Abnormal muscle tone and reflexes
• (ROM) Range of Motion/Contractures
• Systemic functions i.e. bladder, respiratory, circulatory, and digestive
• Loss of bone density
• Standing tolerance and endurance
• Skeletal development
• Balance
• Other
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Altimate Medical, Inc. - makers of EasyStand products ©2007
Letter of Medical Necessity Outline
Current program:
• What is the client's current therapy program at home, school, work & their history of compliance?
• What are their functional goals?
• What other less costly alternatives were considered?
(i.e. ROM , splints, other methods of weight bearing)
• What other medical intervention may be necessary if client cannot receive a stander?
V
(i.e. surgeries, bracing, etc. - approximate cost of other interventions)
Stander considered and/or trialed:
• What equipment was considered (both least and most costly)?
• What equipment was trialed (both least and most costly)?
• What were the outcomes of each trial? Why was each trial either approved or rejected?
VI
Recommendations:
• What equipment is being recommended and why?
• What is the prescribed standing program (i.e. what setting, describe standing program,
minutes/hours per day - time per week)?
• What are the outcomes expected?
Therapist's signature:
date:
Doctor's signature:
date:
* If necessary include a copy of the assessment form, photos and/or videos.
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Letter of
Medical Necessity
IV
Standing Technology
Letter of Medical Necessity #1
RE: John Doe
DX: Microcephaly/CP
Parent:
Address: MN
Date of Birth: 11-18-87
Funding: MA
Phone:
Date: 01-12-99
General Medical Condition:
____is an 11 year old male referred to Rehab Center by Dr._____. ____has a birth history significant for partial deletion of the long
arm of the 1st chromosome. _____ also had a left brachial plexus injury, which affected his diaphragm. ____ was admitted to the
NICU for 4 1/2 weeks. He has history of seizures and apnea. His seizures are controlled by medication at this time. Medications
include Benadryl and Depakote. Past surgical history includes derotation osteotomies 4 years ago, hardware removal 3 years ago and
abdominal surgery 2 years ago. He also has history of metatarsal fracture 1 1/2 years ago. Per mother, ____s cognition is 24
months. He enjoys music. He has a hearing impairment and wears bilateral hearing aids. ___ received Botox injections to bilateral
hamstrings on 8-10-98 and began physical therapy in the pool 9-98. Primary focus is to assist ____ out of his flexed position. Since
____s hip surgery, he has been unable to tolerate LE weightbearing and has developed contractures in his hips, knee and ankles in a
flexor synergy. ____has made gains in the pool with LE extension and is beginning to weightbear with assistance. Because ____ has
grown to significant size, 4'8" and 110 lbs., it is unreasonable to work on standing without the assist of a standing frame. He
requires maximal assist of one or two people to maintain stance for greater than a brief transfer secondary to limited extension and
strength in weightbearing on land. ____ requires maximal assist to transfer. He needs maximal assistance for transitions into/out of
his chair. ____does not ambulate at this time. Per parent, he did take a few steps with assistance for balance prior to his hip
surgery. ____ can sit independently, his primary form of mobility is a modified bunny hop for short distances ( 3-5-feet) . ____
spends a majority of his day in his wheelchair.
Current Program:
At this time ____ does not have a stander available to him at school or home. Secondary to his contractures, ____ will not tolerate a
standard standing frame that requires knee extension along with dorsiflexion at his ankles. But more importantly, it would be
unsafe and impractical to try to lift and position him into a standing frame (prone or supine). _____s mother does his transfers
independently at home and needs a support/standing frame that ___ can be positioned in with one person. ____ also needs a type
of stander that can be slowly moved into extension as he is able to tolerate. ____ will be in his stander daily with parent or PCA.
With increased tolerance of weightbearing and LE extension, ____ will in the future be able to assist with stand pivot transfers into
and out of his wheelchair, toilet and bed.
Equipment Trial:
___ underwent a trial with the EasyStand 5000 which he tolerated well. He demonstrated his tolerance in one session at Rehab
Center and then the stander was utilized at his school for a week which was a positive experience for ____ as well as his therapist
and teacher. He was able to stand for 25 minutes the first session. He was assisted to a sitting position in the EasyStand from his
wheelchair by his mother. ____ was then slowly and gently elevated into weightbearing position with slow increase in hip and knee
extension. He was able to tolerate -25 degrees of knee extension and -30 degrees of hip extension. ___ was able to tolerate more
extension in the stander for a prolonged period of time versus when 2 or more caregivers are attempting to support his stance with 45 to 50 degrees of knee and hip extension. The other plus for this stander is that ___ will be able to utilize this stander into
adulthood.
Recommended Equipment:
Recommended at this time is the EasyStand 5000 with the high back option which includes a seatbelt and a 10" back that has four
seat depth adjustments for growth and chest strap for additional support and safety.
If _____ does not address his hip and knee contractures through weightbearing and prolonged stretch now that he is making some
progress towards extension, his future will hold more surgery and equipment for transfers. (Hoyer) ____ will benefit from
addressing his contractures and limited weightbearing now to ensure his functional independence and participation in transfers in
the future.
Jane Doe , PT
Dr. John Doe
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Letter of Medical Necessity #2
Length of Need:
To Whom It May Concern:
History: Harry is a 3-year-old male with the diagnosis of cerebral palsy. He is non-ambulatory and is dependent upon his parents
for his mobility. He has decreased trunk strength. Without trunk support, he is unable to properly move his upper extremities.
With good trunk support, Harry has fair head control.
Letter of
Medical Necessity
Date:
Harry Smith
Diagnosis:
ICD-9 Code:
Height:
This prescription prepared by:
Harry currently has functional passive motion in his lower extremities. However, given his diagnosis, he is at increased risk of
developing contractures. Standing has been shown to delay the appearance of contractures (1). Because he lacks the strength to
stand, the standing frame will help to keep him in a good position to stretch these muscles for extended periods. This stretch will
maintain and improve his lower extremity range of motion.
Harry has increased spasticity throughout his lower extremities. Standing has been shown to decreased spasticity in children with
cerebral palsy (2). Decreasing his spasticity will assist in maintaining range of motion and improving his overall level of function.
Children without disabilities stand between 8-10 months of age. This standing helps with the forming of the acetabulum (3). It is
very important in children with disabilities to get them standing at a young age. Because of Harry’s diagnosis, he is already at
increased risk of developing hip subluxation as he grows. Standing will increase the depth of his acetabulum and decrease his risk of
subluxation.
Harry will benefit from a standing frame that can position him properly in standing. Standing also facilitates better emptying of his
bladder, which can decrease his risk of developing urinary tract infections (4).
Harry is at increased risk of developing osteoporosis due his inability to stand independently (5, 6). This standing frame will allow
Harry to bear weight through his lower extremities. Because it is easy to move the frame from a seated to a standing position, his
parents will be able to change his position frequently. Consequently, he will get dynamic loading of his bones rather than just static
loading. Research has shown that more dynamic weight bearing results in less of a loss in bone mineral density (7). This will
provide him with the maximal benefits from standing.
The other benefits of standing are well established. In addition maintaining his lower extremity range of motion, which is important
for him, a standing frame has many benefits. Standing has been shown to improve circulatory, gastrointestinal, bowel and bladder,
and respiratory functions (3,4).
Harry has normal sensation in his buttocks but, due to his decreased active lower extremity motion, he cannot move himself
independently to shift his weight. This puts him at an increased risk of developing decubitus ulcers (4). People who stand for at
least 30 minutes a day have less pressure sores than those who do not stand (8).
The use of a stander will benefit Harry psychologically. It will increase his self-esteem by allowing him to have eye to eye
conversations with his peers. This decreases his risk of developing depression as he gets older and his peers grow taller, making the
height difference even greater.
Current Program:
At this time, Harry has a loaner standing frame at home. He does not have any type of wheelchair or positioning chair. His mother
transfers him independently at home and needs a standing frame that can be easily operated by only one person. His mother has
tried the recommended stander and she is able to use it successfully.
Harry is currently at the smallest height for using this stander. Consequently, it has good growth potential and he will be able to use
it for a maximal amount of time. Additionally, the recommended equipment positions Harry well in both sitting and in standing.
Harry will be in his stander daily. With increased tolerance of weight bearing and lower extremity extension, one goal is for him to
be able to assist with stand pivot transfers. As stated above, the many benefits from using a stander include improved bone mineral
density, maintenance of lower extremity range of motion, improved bowel and bladder function, and decreased risk of developing
decubitus ulcers. Additionally, because of the good trunk support, he will use it while he works on different reaching activities, such
as turning pages in books, playing with toys, and working with a communication device as appropriate. (continued)
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Altimate Medical, Inc. - makers of EasyStand products ©2007
After a full examination by the rehabilitation team and Harry’s family, the following equipment is deemed medically necessary:
1. EasyStand Comfy Seat Magician with:
A. Headrest: This is necessary to properly support his head given his decreased head control. Without this, if his head
goes backward, he will be unable to return it to an upright position.
B. Secure Foot Option: Given his spasticity, this option is necessary to keep his feet positioned properly. This will ensure
equal weight bearing.
The benefits of standing are well established. In addition to improving his lower extremity range of motion, a standing frame has
many benefits. Standing can improve circulatory, gastrointestinal, bowel and bladder, and respiratory functions. It can assist with
normal skeletal development, increase strength, and decrease spasticity. Additionally, it can increase his peer interactions because
he will be at a normal height as opposed to sitting on the floor or in a chair.
If you desire any further information on the benefits of standing, we would be glad to provide it to you.
Thank you for your assistance in maximizing the client’s function.
Sincerely,
Jane Doe, M.D.
John Doe, MPT, ATP
References
1. Vignos, P., Wagner, M., & Karlinchak, B. Evaluation of a program for long-term treatment of Duchenne muscular dystrophy.
JBJS. Vol 78-A, NO 12, December 1996. 1844-1852
2. Tremblay, Malouin, Richards, & Dumas. Effects of prolonged muscle stretch on reflex and voluntary muscle activations in children with spastic cerebral palsy. Scand J Rehab Med, 1990 22: 171-180
3. Stuberg WA. Considerations related to weight-bearing programs in children with developmental disabilities. Physical Therapy.
72(1):35-40, 1992 Jan.
4. Dunn, R. B., Walter, J. S., Lucero, Y., Weaver, F., Langbein, E., Fehr, L., Johnson, P., & Riedy, L. Follow-up assessment of standing
mobility device users. Assist Technol, 10(2), 84-93, 1998
5. Whedon GD. Changes in weightlessness in calcium metabolism and in the musculoskeletal system. Physiologist. 25(6):S41-4,
1982 Dec.
6. Henderson, R., Kiaralla, J., Abbas, A & Stevenson, R. Predicting low bone density in children and young adults with quadriplegic
cerebral palsy. Dev Med Child Neurol. 46: 416-419, 2004
7. Thompson CR. Figoni SF. Devocelle HA. Fifer-Moeller TM. Lockhart TL. Lockhart TA. From the field. Effect of dynamic weight
bearing on lower extremity bone mineral density in children with neuromuscular impairment. Clinical Kinesiology. 54(1):13-8,
2000 Spring
8. Walter JS. Sola PG. Sacks J. Lucero Y. Langbein E. Weaver F. Indications for a home standing program for individuals with spinal
cord injury. Journal of Spinal Cord Medicine. 22(3):152-8, 1999 Fall
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Date: 10/05/99
John Doe
Diagnosis: T12 paraplegia complete
Height: 5'10" Weight: 155 lbs ICD-9 Code: 806.25
This prescription prepared by: PT Length of Need: Lifetime
Equipment: EasyStand Evolv Glider
STATEMENT OF MEDICAL NECESSITY:
Letter of
Medical Necessity
Letter of Medical Necessity #3
The EasyStand Evolv Glider is being recommended for ________ for a number of issues which will be listed below. ________'s
primary diagnosis is T12 complete paraplegic related to a spinal cord injury suffered on 4/22/99. He has recently discontinued use
of a TLSO which was providing support through his thoracic spine while his surgical site due to the placement of supportive rods
was healing. Since he has begun outpatient rehab physical therapy, he has been very motivated to maintain and increase his
strength and endurance and also to be very proactive in his general care and maintenance. The EasyStand Evolv Glider has a
number of indications which will assist ________ in his ability to independently carry out a number of medically necessary
self-care issues. ________ has demonstrated appropriate use and consistent use of the Evolv Glider that we have in our clinic
setting. He has come in approximately 3 days a week on his own to actively stand for as much as 20 minutes on the Evolv Glider.
He is independent in set-up, transfer to and from the device, and monitoring his cardiovascular status and other physiological
parameters while utilizing the device.
The medical benefits of a standing program, in particular the active standing program that is provided by the Evolv Glider, are
numerous. This will act as a very effective augmentation to his present ROM program. The feet are placed in such a position as
to assure good ROM through the ankles while operating the glider. His knees are supported in full extension, and he gets good
hip extension ROM while using the glider. The most common areas of contracture formation and loss of ROM in this population
is in the short hip flexors and in the ankles and knees due to prolonged periods of sitting. The Evolv Glider provides ROM out of
these positions in a more dynamic and fluid manner. Therefore, the Evolv Glider would allow ________ to independently range
himself in a very functional and effective manner.
Also, in the realm of ROM and flexibility, the reciprocating arm movement that is achieved through the glider encourages good
thoracic level and spinal rotation which maintains ROM throughout the spine. It also supports a good upright posture with
thoracic extension and a good cervical position as well. This counters the kyphotic posture that is encouraged and in some ways
necessary when operating a manual wheelchair for long periods of time during the day. An upright standing program,
particularly when this dynamic, also has other systemic benefits. These include improved respiration and ventilation due to the
upright posture and cardiovascular activity. Improved bowel and bladder function have been documented in relation to a
consistent standing program in that there is gravity assistance and elongation through the trunk, enhancing digestive bowel and
bladder function. It can also be theorized that with this increased up time intermittent catheretization can be done more
completely to decrease the risk of urinary tract infections, again another common secondary complication related to complete
spinal cord injury. There is also a significant strength benefit that can be gained through a dynamic standing program such as
with the Evolv Glider. When utilizing the UE's, ________ demonstrates good rotation through the spine as noted earlier. This
encourages muscle development throughout the paraspinal musculature about the level of his injury, increasing dynamic
stability in this region and also assisting with dynamic posture control. Again, a common complication observed with thoracic
level paraplegic is an increased thoracic kyphosis due to the posture taken during propulsion of a manual wheelchair.
Other options were looked into in regards to ________ 's particular case. Utilizing his wheelchair for strengthening is
contraindicated due to the fact that the repetitive and extreme movements required for wheelchair propulsion have been linked
towards increased instance of shoulder, wrist and elbow pathologies, not to mention the increased thoracic kyphosis noted above.
Therefore, utilizing his wheelchair for strengthening in addition to general daily usage is contraindicated. We also looked into a
variety of other programs and facilities around town and found that many of these environments provided good equipment for UE
strengthening and in some cases thoracic level paraspinal strengthening, however no one allowed ________ to maintain an
upright posture during this process which encourages increased ventilation and respiration. We found that the Evolv Glider not
only provided us with the general health benefits that are encouraged through this device, but allowed ________ to perform
these in an upright standing posture such that he could accomplish his weight bearing, ROM and other self-care tasks at the
same time.
In summary, we are strongly recommending that he obtain a Evolv Glider to assist in his goal of independent self-management
and decreased risk of secondary complications related to spinal cord injury.
John Doe, PT
Jane Doe, MD
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Letter of Medical Necessity #4
Date:
Jane Doe
Diagnosis:
Height:
ICD-9 Code:
This prescription prepared by:
Length of Need:
To Whom It May Concern:
I am writing to request funding for a medically necessary EasyStand _________ for my patient,
_________________________.
________________ is ___ year-old female. Her height is 5’1’’ and her weight is 80 lbs. She lives with her foster mother
and father: her foster mother is her primary caregiver. She presents with a diagnosis of cerebral palsy, mental
retardation, and developmental delay. She is fed via a feeding tube, and she is incontinent of bowel and bladder.
_________ does not purposely weight shift and is at risk for skin breakdown. Her only source of mobility is her
wheelchair, for which she is dependent. At this time, her foster mother can transfer her from all surfaces to bed and
wheelchair. However, this is becoming difficult, as _____ does not assist with the transfers. __________ (_______’s
caregiver) cannot help _______ purposefully stand by holding her, as she is growing.
The stander requested will enable my patient to reach her goals of promoting skin integrity, preventing skin breakdown,
and improving postural alignment - thereby preventing further surgery related to poor positioning and posture. Other
goals for _______ that the EasyStand_________ will promote are improved circulation, decreased muscle spasms and
atrophy of leg muscles, reduced disuse osteoporosis, and the promotion of bone integrity. Furthermore, the EasyStand
will improve ______’s ability to interact with her environment.
The EasyStand best suits ______’s overall needs. It tolerates a one-person transfer, starting from a seated position and
slowly raising to a standing position. This stander and its accessories accommodate ______’s shorter leg and externally
rotated hip. Each place of the stander can be adjusted independently of one another. _______ tolerates the transfer
without difficulty, and can stand for increasing periods of time. Her caregivers will be responsible for carrying out the
stander program developed for _______. Compliance will be greater with the EasyStand because it tolerates a
one-person transfer. With its use, ______ will receive the maximum benefits of standing.
________ has been assessed using a variety of standing programs, the last involving a prone stander. This stander is not
appropriate at this time, as it does not accommodate all of ________’s needs. She is resistant to quick position change
and touch. _______ is sensitive to tactile stimuli - when touched, She pulls away, curling up her legs and arms, and
rolling her hips from side to side. Additionally, she pulls her legs and arms into flexion. As a result, it takes three people
to transfer __________. She fights not to be transferred to the prone stander. As one person holds her down, others
must attempt to strap her legs in place, then strap her arms in while holding down her hips. She is at risk during this
transfer for falls, bruises, and possible dislodging of her feeding tube. ________ is becoming taller - thus, it is difficult to
transfer her from a seated wheelchair to a straight stander. Previous to the prone stander, a freedom stander was
utilized. Neither of these standers is being used at this time, due to the problems they create. However, when these
standers were viable, ______ was regularly placed in one of them. At this point, though, these standers do not provide
the support _________ requires to be safe. She requires a chest support, hip guides, and other listed adaptations.
When _______ was participating in a standing program, she was providing Mod A with her transfers. She bore weight
and reached with her arms for her wheelchair. Since ________ has not been able to stand for long periods of time, she is
losing her ability to actively assist with weight bearing and transfer activities.
_______’s standing program will include standing every day, starting with her baseline - assessed in the EasyStand as 20
minutes at an 80-degree incline - gradually increasing her tolerance over time. Her program will include standing 45
minutes to one hour at 90 degrees, 2 to 3 times daily. As ______ continues to participate in this standing program, the
goals will induce increasing her active participation in stand and pivot transfers.
If you need additional information, please call me at (000) 000-0000. Thank you,
Sincerely,
______________Therapist
______________Physician
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Letter of Medical Justification
John Doe
DOB:
6.30.79
Diagnosis: C6 ASIA A SCI
Onset: 11.14.00
Height: 5’9”
Weight: 61.4 kg
Primary Funding: Medicaid
I. Brief Medical History:
John sustained C5 C6 fractures in MVA on 11.14.00. He underwent fusion on 11.21.00. He also sustained right
acetabular fracture and left navicular fracture-dislocation during the crash. There was no reported loss of
consciousness. He was placed on a ventilator with trach on 11.27.00. After stabilization he was transferred to
_______ for rehabilitation. He was admitted with C3 ASIA A diagnosis and was vent dependent. He was weaned
from the vent and was discharged home verbally independent and able to drive a sip and puff power wheelchair.
John has made significant gains over the course of his injury and has responded well to phased rehab stays at
_______. At the most recent stay his ASIA score had improved to C6 with a zone of partial preservation into C7.
Due to a history of recurrent urinary tract infections John has now transitioned to intermittent catherization
program and has adjusted his bowel program to decrease from 2 hour to just under one hour. He has had a
history of skin breakdown, which is currently resolved. He is now able to drive a power wheelchair with a joystick
in the community and can propel a manual wheelchair in accessible even surfaces for short distances. He assists with
transfers at the max assist level.
II. Current Function:
Ambulation: Nonambulatory due to level of SCI. Does tolerate passive standing in therapy well.
Transfers: One plus pivot for uneven-dependent. Assists at mod/max assist for even with board.
Activities of Daily Living: Feeds self. Completes basic hygiene with set up- min assist. Requires assist for
dressing and bathing. He is able to instruct others.
Mobility: John uses a power wheelchair with tilt in space for pressure relief in community and often at home.
He is able to propel a manual wheelchair on even surfaces for a limited distance.
School: John has been in communication with Voc Rehab and plans to attend college in the coming year.
Transportation: John has an accessible van, but is not yet driving himself.
III. Physical/ Medical Condition
• ROM: John receives daily stretching to his trunk and lower extremities but struggles as most individuals with
SCI to maintain range due to positioning and tone especially in the hip flexor and heelcord areas. When trailing
the EasyStand Evolv Glider he increased his range to within normal limits at both these key areas due to the
reciprocating lower extremity movement that keys these problem areas.
• Tone/Spasticity: John exhibits significantly high lower extremity and trunk spasticity, which makes mobility and
transfers challenging and creates a safety risk. Spasms cause difficulty with maintaining proper wheelchair
positioning which could lead to skin breakdown and also cause for discomfort and interrupted sleep patterns.
Spasticity also leads to ROM loss and contractures. For John to consider driving in the future his spasticity must
be under good control. Notable decreased in tone/spasticity occurred during trials of the EasyStand Evolv Glider.
• Bowel/Bladder Function: John has a history of recurrent UTI’s and long bowel program routine. Standing has
been shown to decrease UTI’s and time required for bowel program completion due to normalizing the
physiologic function in the upright position for complete emptying and motility.
• Maintain Bone Integrity: John is at high risk for long term osteoporosis due to lack of weight bearing and muscle
stress on long bones. The increase in calcium can contribute to renal stones of which John has a history.
Normalizing weight bearing and stress on the long bones as provided by the Evolv Glider may assist in reducing these
medical complications. (continued)
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Letter of
Medical Necessity
Letter of Medical Necessity #5
(continued)
• Cardiovascular: After SCI an individual loses many avenues of cardiovascular challenge due to the inactivity
of the larger muscle groups which are located predominately in the lower extremities. Standing challenges the
cardiovascular system normalize by requiring the heart to pump the blood flow “against gravity” in the upright
posture. The Easystand Evolv Glider also provides and upper body strengthening that John is able to complete while
he is standing further conditioning the cardiovascular system.
• Skin Integrity: Due to absent gluteal region sensation, limited mobility, and atrophied gluteal musculature,
John is at high risk and infact has a history of skin breakdown. Passive standing provides an alternate upright
position for the body that does not focus pressure on the ishial bones. The increase in cardiovascular function
further decreases skin breakdown risk due to increased oxygenation to the tissues.
• Balance Restoration: John has been working on balance strength and compensatory strategy in preparation for
improved transfer skills. While in the Easystand Evolv Glider John is provided with a safe environment to focus on trunk
stabilization and mobility especially through the reciprocal arm/leg movement of the Glider.
IV. Current Program: John currently does a home therapy program with family
• Assist and also attends outpatient services. It is his goal to transition to a more independent program in prep
for beginning school. An Easystand Evolv Glider will be integral to this transition providing benefits of standing, ROM,
tone reduction, postural control, and cardiovascular strength all in one program that can be completed in a home
setting. Facilities close to John do not have a standing frame for his use in the therapy setting.
• In addition to making John more independent in his life wellness program, the standing program recommended
can save cost to payer sources by decreasing the possibility of treatment required for UTI’s, attendant care for
long bowel programs, wound care or potential flap surgeries, and increased tone intervention such as tendon
releases or baclofen pump placement: etc.
V. Equipment Trial: John trailed several standers during his phased program.
• The Strap Stander did not provide adequate trunk support (although not needing to transfer to device was a plus)
Required assist of 2 persons to come to position.
• Standing Power Wheelchair: Client preferred the drive feel of a rear wheel drive wheelchair and the stander
power wheelchair was front wheel drive. Considerable cost savings to have a separate stander instead of the
cost of integrating the stander on his power chair.
• Easystand Evolv: Provided proper standing position but was not as effective at tone reduction as the
recommended equipment and did not incorporate the upper body strength and trunk balance components of
the equipment specified.
• Easystand Evolv Glider: John was able to tolerate 30 minutes in this unit on numerous trial occasions with excellent
results for cardiovascular enhancement, tone reduction, increased ROM, and decreased bowel program times.
His mother was able to set up the system and complete transfer and positioning help as needed.
VI. Recommendations:
• Based on the above information the Easystand Evolv Glider is recommended as the most appropriate standing
system for John. Specific order information and pricing is attached. It is recommended that John use the system
at least 30 minutes 5 times per week in the home setting to obtain benefits described in part III.
Therapist:
Date:
Physician:
Date:
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Date:
John Doe
Diagnosis:
Height:
ICD-9 Code:
This prescription prepared by:
Length of Need:
To Whom It May Concern:
History:
John is an 8-year-old with a diagnosis of spinal muscular atrophy. He has decreased trunk strength and control. Without trunk
support, he is unable to properly move his upper extremities. This limits his ability to move against gravity, explore his
environment, play, and perform activities of daily living.
Letter of
Medical Necessity
Letter of Medical Necessity #6
John has tight hip flexors. Additionally, his hamstring muscles are tight bilaterally as evidenced by his increased popliteal angles.
Because he lacks the strength to stand, the standing frame will help to keep him in a good position to stretch these muscles for
extended periods. This stretch will improve his lower extremity range of motion. John has scoliosis and he wears a
thoracolumbar sacral orthosis to assist him in maintaining an upright position and to slow the progression of the curve. His
breathing is also compromised due to his weakness and his scoliosis.
Current Program:
At this time, John does not have a stander or a positioning chair available to him at home. It would be unsafe and impractical to
try to lift and position him into a regular prone or supine standing frame. John’s father has tried the recommended stander and
he is able to use it successfully.
John will be in his stander daily. The goal of standing is for him to increase his tolerance of weight bearing and to increase his
lower extremity extension. Additionally, because of the good trunk support, he will use it while he works on different upper
extremity activities such as playing games or doing school work.
Recommended Equipment:
The current recommended device would serve two purposes for John. It can be used as a positioning chair for seated activities in
addition to a stander. The proposed stander has maximal growth capability so it will last a longer amount of time.
After a full examination by the rehabilitation team and John’s family, the following equipment is deemed medically necessary:
1. EasyStand 5000 Youth Stander with:
A. Locking Casters: These will allow the stander to be safely placed so that it cannot accidentally be moved which could
result in injury.
B. Table Swing-away Sleeve: This will allow the table to be swung out of the way for increased ease and safety when
transferring John in and out of the stander.
C. Hip guides: Given his lack of trunk control, these are necessary to keep his hips from sliding sideways in the stander.
D. Back Option: This is the simple back support needed to provide him with postural support.
E. Seat Belt: This is a standard, no charge option
F. Clear Desk Table: This is a standard, no charge option
G. Chest Strap- Small: Given John’s decreased trunk control, this is necessary to keep him positioned properly and safely
when going from sit to stand. Without the strap, he falls forward when changing positions, which can result in injury.
H. Lateral Supports: Given John’s decreased trunk control, these are necessary to give him the needed support to remain
in an upright position. Without these, he will be at increased risk of injuring himself because if he starts to fall laterally,
he does not have the strength to upright himself.
The benefits of standing are well established. In addition to improving his lower extremity range of motion, a standing frame has
many benefits. Standing can improve circulatory, gastrointestinal, bowel and bladder, and respiratory functions. Additionally, it
can assist with normal skeletal development.
If you desire any further information on the benefits of standing, we would be glad to provide it to you. Thank you for your
assistance in maximizing the client’s function.
Sincerely,
____________
MD
____________
MPT, ATP
____________
PT
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OTR/L
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By: Ben Mattlin
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Stand Today for a
Healthy Tomorrow
You probably stood in rehab . . .
But did your therapist prescribe a
stander for you to use at home?
It’s not too late to start standing.
Talk to your PT about standing today
and reap the benefits tomorrow.
800•342•8968
www.easystand.com
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™
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Creative
SECURING FUNDING FOR
POST-ADOLESCENTS
BY SANDRA L. BIENKOWSKI
Solutions
A
Many school-aged children
receive funding for assistive technology devices from a myriad of
private or public funding sources.
The Individuals with Disabilities
Education Act authorizes special
education and related services for
students with disabilities, and
requires that students are evaluated for their assistive technology
needs. But what happens when
these school-aged children reach
adulthood and turn 21? Suddenly
their funding options narrow significantly. Gone are the days of
full coverage, and many 21-year
olds are left with coverage for
only the most basic of assistive
devices.
When their funding choices
are reduced, young adults can
still secure funding of assistive
devices using a thorough review
of documentation and tapping
into a little creativity.
“The solutions for young adults
and adults who need assistive
technology, DME products and
services, become smaller and
limited in regards to funding
solutions. The most important
rule is to be creative and persistent in looking for funding solutions,” says David Kron, dealer
support and customer service for
Freedom Concepts, Winnipeg,
Canada.
“Create the argument and
rationale now. You need to sell
them — the funder — on why they
need to approve the claim; it is too
easy to say, ‘no.’ Use a process of
elimination for the funding,” Kron
explains.
The client or caregiver needs
to create a funding strategy for
their individual case, but the first
step is to review documentation.
Nancy Perlich, product
development and reimbursement
specialist, Altimate Medical,
Morton, Mass., received the call
from the mother whose son
suffered from CP and couldn’t
secure funding for a much-needed
stander. Perlich first reviewed the
documentation.
“I have found that regardless of
age, if funding sources deny the
assistive technology, it is best to
review the documentation that
was submitted. If the
documentation is complete,
resubmit or appeal. If the
documentation is not as clear as it
should be, have the Letter of
Medical Necessity (LMN) written
clearly. Include trial information
and make sure that the LMN
addresses the specific medical
need of the client, not just general
benefits that the assistive technology will give to a similar diagnosis.”
Kron suggested a 10-point plan
in composing a funding strategy
(see sidebar).
In the case of this 21-year-old,
his LMN was complete, but he
was denied twice.
When coverage is denied, it is
time to appeal.
“My suggestion to the mother
was to contact her local
Protection Advocacy for Assistive
Technology Office (PAAT). I
explained that the PAAT
REPRINT FROM MOBILITY MANAGEMENT - NOVEMBER 2004
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young adult has CP. The mother calls a funding hotline in frustration after her 21-year old son was twice denied coverage for a new
stander because of his age. When he was a child and teenager his
stander was covered. The stander provided him with weight bearing in the upright position and a prolonged stretch to his hips, knees
and ankles, helping him to maintain his range of motion. His mother
thought that the upright position greatly aided his respiratory system
and allowed him to gain a productive cough, keeping him from getting
pneumonia. Not only was she frustrated with the funding source, but it
was becoming increasingly difficult to find physicians who understood
her son’s complete medical needs since he was no longer followed by a
pediatric staff at the CP clinic. She described her son as turning 21
and falling off the face of the earth. After two failed attempts to secure
a stander through insurance, where could she turn for help?
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M
STANDING DEVICES
The development of devices to enable people with SCI to
engage in home-based therapeutic standing activities has
been reported as early as the 1960s.2 In a survey of a community-based sample of people with SCI, we found that 30%
of these individuals engaged in prolonged standing activities as a method to improve or maintain their health.3
Home-based standing activity can be undertaken through
different forms of assistive technology, and three general
types are described here:
•Orthoses
•Standing frames and standing wheelchairs
•Functional electrical stimulation (FES)
We found that approximately half of the individuals with
SCI who participated in regular standing used a standing
device while the other half used braces (orthoses) and/or
walking aids (forearm crutches, walker).3
ORTHOSES
Individuals who have some residual motor function of
the arms and trunk musculature, but varying motor function of the lower extremities, may be able to engage in
standing using conventional orthoses. The conventional
knee-ankle-foot orthosis (KAFO) consists of a shoe, ankle
joint, knee joint, medial and lateral metal or plastic uprights,
calf band, knee pad, and thigh band. The KAFO provides a
BY JANICE J. ENG, PHD, PT/OT
Standing systems offer a
wide variety of health
benefits for those who
suffer from SCI.
mechanical support against gravity and locks
the knees in extension so they will not collapse. However, it is still possible to tip over or
collapse at the hip, and thus, sufficient head,
trunk, and hip control is necessary. Forearm
crutches or walkers are used in conjunction
with the orthoses. Modified versions have a
molded ankle-foot orthosis instead of an ankle
joint. The reciprocating gait orthosis adds reciprocating hip joints connected by cables, a molded pelvic
band, and upright supports for the thorax and can accommodate people with higher thoracic level injuries.
Although the KAFO and reciprocating gait orthosis are
intended for ambulation, their high energy cost during
walking often results in the use of these orthoses for standing exercise only. For example, one study tracked 147
cases of people with a complete SCI (LI or above) who had
been prescribed a Craig-Scott orthosis (modified KAFO),
and it was found that more than 50% of these people used
the orthosis for therapeutic standing, rather than walking.4
Given the cost of customized orthoses, the need for intensive training to use these orthoses safely, and the time and
effort to don and doff the braces, other alternative standing
devices may be more appropriate if the purpose is only for
standing activities.
STANDING FRAMES AND WHEELCHAIRS
Standing frames and standing wheelchairs provide a
mechanical support against gravity so the person can maintain an upright posture. The most basic standing frame is a
simple padded wooden or metal frame with a wide base,
front table attachment for resting the arms, and straps and
pads to hold the legs and trunk in the frame. Clients must
pull themselves to their standing position or be assisted to
standing by a caregiver or mechanical lift.
More expensive devices ($2,000-$6,000) integrate
hydraulic or electrical systems to tilt a chair seat and back
support forward and upward so that the client rises passively from sitting to rest against a padded frame in the
upright standing posture. Space can be an issue in the
home setting as these standing frames will require significant floor space and are not easily stored in conventional
closets. Standing frames that are fully integrated within a
manual or powered wheelchair are also available but are
more expensive ($10,000-$20,000). The advantage of the
integrated unit is that for some individuals, standing activities can then be incorporated into daily functional activities, such as moving around a workspace and reaching
high shelves.
Getting Up
Goals
Reprinted with permission. Getting Up Goals,
Rehab Management, January/February 2004; Volume 17, Number 1: Pages 34, 36, 37 & 62.
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ore than 1,700,000 adults and children in the
United States use wheelchairs for daily
mobility in their community.1 People who are
dependent on wheelchair mobility and are
unable to stand independently may benefit
from assistive technology to engage in standing activity. Standing activity can benefit persons with limited mobility resulting from
congenital conditions or from musculoskeletal or neurological injuries.
In particular, people with spinal cord injury (SCI) are at
great risk for a number of secondary complications due to
chronic immobilization, which could be potentially counteracted with regular standing activity. The effects of a SCI are
far-reaching and they impact the functioning of multiple
body systems including the cardiovascular, respiratory,
musculoskeletal, urinary, and digestive systems. Following
a SCI, the majority of people experience complications such
as pressure sores, urinary tract infections, osteoporosis,
contractures, spasticity, and orthostatic hypotension (a drop
in blood pressure immediately upon moving to an upright
posture, which can result in dizziness and fainting).
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Research Studies
Research Studies
Research Studies
Abstracts
Numerous research studies have been conducted on the benefits of standing. For your reference, we have compiled
a list of research articles and abstracts documenting the benefits of standing. For the complete document, please
visit www.pubmed.com or your local medical library. Altimate Medical also has copies of most of the research
studies, contact Nancy Perlich at 877-844-1172.
Bone density and metabolism in children and adolescents with moderate to severe
cerebral palsy.
Pediatrics. 2002 Jul;110(1 Pt 1):e5.
Henderson RC, Lark RK, Gurka MJ, Worley G, Fung EB, Conaway M, Stallings VA, Stevenson RD.
Department of Orthopaedics, University of North Carolina, Chapel Hill, North Carolina 27599, USA.
[email protected]
OBJECTIVES: Diminished bone density and a propensity to fracture with minimal trauma are common in children
and adolescents with moderate to severe cerebral palsy (CP). The purpose of this study was to provide a detailed
evaluation of bone mineral density (BMD) and metabolism in this population and to assess the relationship of
these measures to multiple other clinical, growth, and nutrition variables. METHODS: The study group consisted of
117 subjects ages 2 to 19 years (mean: 9.7 years) with moderate to severe CP as defined by the Gross Motor
Functional Classification scale. Population-based sampling was used to recruit 62 of the participants, which allows
for estimations of prevalence. The remaining 55 subjects were a convenience sampling from both hospital- and
school-based sources. The evaluation included measures of BMD, a detailed anthropometric assessment of
growth and nutritional status, medical and surgical history, the Child Health Status Questionnaire, and multiple
serum analyses. BMD was measured in the distal femur, a site specifically developed for use in this contracted
population, and the lumbar spine. BMD measures were converted to age and gender normalized z scores based
on our own previously published control series (n > 250). RESULTS: Osteopenia (BMD z score <-2.0) was found in
the femur of 77% of the population-based cohort and in 97% of all study participants who were unable to stand
and were older than 9 years. BMD was not as low in the lumbar spine (population-based cohort mean +/- standard error z score: -1.8 +/- 0.1) as in the distal femur (mean z score: -3.1 +/- 0.2). Fractures had occurred in 26%
of the children who were older than 10 years. Multiple clinical and nutritional variables correlated with BMD z
scores, but interpretation of these findings is complicated by covariance among variables. In stepwise regression
analyses, it was found that severity of neurologic impairment as graded by Gross Motor Functional Classification
level, increasing difficulty feeding the child, use of anticonvulsants, and lower triceps skinfold z scores (in decreasing order of importance) all independently contribute to lower BMD z scores in the femur. CONCLUSIONS: Low
BMD is prevalent in children with moderate to severe CP and is associated with significant fracture risk. The
underlying pathophysiology is complex, with multiple factors contributing to the problem and significant variation
between different regions of the skeleton.
PMID: 12093986 [PubMed - indexed for MEDLINE]
Bone dynamics: stress, strain and fracture.
J Sports Sci. 1987 Summer;5(2):155-63.
Martin AD, McCulloch RG.
Sport and Exercise Sciences Research Institute, University of Manitoba, Winnipeg, Canada.
Bone is a dynamic tissue whose functional mass is controlled by the balance between the endocrine drive
towards bone resorption and the mechanically-engendered drive towards bone formation. Strain is the key intermediate variable between loading forces and bone remodeling. Animal studies have shown that static loading of
bone has no osteogenic effect; bone loss occurs as if there were no loading at all. However, dynamic loading, that
is, cyclic change in internal strain, is strongly osteogenic, with relatively few cycles required for maximum effect.
However, if a sufficient number of cycles is applied, repetitive loading can cause stress fractures. This number
decreases as internal strains increase. Thus strain redistribution within bone, as caused by muscle fatigue or
improper sports equipment, is a significant cause of fracture.
PMID: 3326949 [PubMed - indexed for MEDLINE]
Page 51
Bone mineral status in paraplegic patients who do or do not perform standing.
Osteoporos Int. 1994 May;4(3):138-43.
Goemaere S, Van Laere M, De Neve P, Kaufman JM.
Department of Rheumatology, University Hospital of Ghent, Belgium.
Bone mineral density (BMD) was assessed by dual-photon X-ray absorptiometry at the lumbar spine (L3, L4), the
proximal femur and the femoral shaft, and by single-photon absorptiometry at the forearm in 53 patients with
complete traumatic paraplegia of at least 1 year's duration and in age- and sex-matched healthy controls. The
patients did (n = 38) or did not (n = 15) regularly perform passive weightbearing standing with the aid of a standing device. Compared with the controls, the BMD of paraplegic patients was preserved in the lumbar spine and
was markedly decreased in the proximal femur (33%) and the femoral shaft (25%). When considering all patients
performing standing, they had a better-preserved BMD at the femoral shaft (p = 0.009), but not at the proximal
femur, than patients not performing standing. BMD at the lumbar spine (L3, L4) was marginally higher in the standing group (significant only for L3; p = 0.040). A subgroup of patients performing standing with use of long leg
braces had a significantly higher BMD at the proximal femur than patients using a standing frame or a standing
wheelchair (p = 0.030). The present results suggest that passive mechanical loading can have a beneficial effect
on the preservation of bone mass in osteoporosis found in paraplegics.
PMID: 8069052 [PubMed - indexed for MEDLINE]
Arch Phys Med Rehabil. 1978 Oct;59(10):447-50.
Kaplan PE, Gandhavadi B, Richards L, Goldschmidt J.
Calcium metabolic balance determinations, which have been done in various clinical and experimental conditions,
were applied to the study of 8 spinal cord injured patients receiving a diet with 1600 mg calcium and 85 to 120
gm protein daily. All of the patients had hypercalciuria prior to ambulation. Those with spinal cord injuries of less
than 3 months duration (early group) had a calcium balance of -27 mg before ambulation and 235 mg after ambulation. Patients with spinal cord injuries of 6 months or more duration (late group) had calcium balances of 55 mg
before ambulation and 175 mg after ambulation. Ambulation significantly decreased the hypercalciuria and modified the calcium balance in a positive direction. Smaller changes were noted in the responses of the late group
than in those of the early group. Early ambulation will probably prevent bone loss, calcium stones in the genitourinary tract, and other sequellae of negative calcium balance.
PMID: 718407 [PubMed - indexed for MEDLINE]
Case study to evaluate a standing table for managing constipation.
SCI Nurse 2001 Summer;18(2):74-7.
Hoenig H, Murphy T, Galbraith J, Zolkewitz M.
Duke University Medical Center, Durham, North Carolina, USA.
Standing devices have been advocated as a potentially beneficial treatment for constipation in persons with spinal
cord injury (SCI); however, definitive data are lacking. A case of a patient who requested a standing table to treat
chronic constipation is presented as an illustration of a method to address this problem on an individual patient
level. The patient was a 62-year-old male with T12-L1 ASIA B paraplegia who was injured in 1965. The patient was
on chronic narcotics for severe, nonoperable shoulder pain. His bowel program had been inadequate to prevent
impactions. A systematic approach was used to measure the effects of a standing table on frequency of bowel
movements (BMs) and on length of bowel care episodes. There was a significant (p < 0.05) increase in frequency
of BMs and a decrease in bowel care time with the use of the standing table 5 times/week versus baseline. For
this patient, the use of the standing table was a clinically useful addition to his bowel care program.
PMID: 12035465 [PubMed - indexed for MEDLINE]
Page 52
Research Studies
Calcium balance in paraplegic patients: influence of injury duration and ambulation.
Research Studies
Abstracts
Changes of tibia bone properties after spinal cord injury: effects of early intervention.
Arch Physical Medicine Rehabilitation. 1999 Feb;80(2):214-20.
de Bruin ED, Frey-Rindova P, Herzog RE, Dietz V, Dambacher MA, Stussi E.
Department of Material Sciences, Laboratory for Biomechanics ETH, Zurich, Switzerland.
OBJECTIVE: To evaluate the effectiveness of an early intervention program for attenuating bone mineral density
loss after acute spinal cord injury (SCI) and to estimate the usefulness of a multimodality approach in diagnosing
osteoporosis in SCI. DESIGN: A single-case, experimental, multiple-baseline design. SETTING: An SCI center in a
university hospital. METHODS: Early loading intervention with weight-bearing by standing and treadmill walking.
PATIENTS: Nineteen patients with acute SCI. OUTCOME MEASURES: (1) Bone density by peripheral computed
tomography and (2) flexural wave propagation velocity with a
biomechanical testing method. RESULTS: Analysis of the bone density data revealed a marked decrease of trabecular bone in the nonintervention subjects, whereas early mobilized subjects showed no or
insignificant loss of trabecular bone. A significant change was observed in 3 of 10 subjects for maximal and minimal area moment of inertia. Measurements in 19 subjects 5 weeks postinjury revealed a
significant correlation between the calculated bending stiffness of the tibia and the maximal and minimal area
moment of inertia, respectively. CONCLUSION: A controlled, single-case, experimental design can contribute to an
efficient tracing of the natural history of bone mineral density and can provide relevant information concerning
the efficacy of early loading intervention in SCI. The combination of bone density and structural analysis could, in
the long term, provide improved fracture risk prediction in patients with SCI and a refined understanding of the
bone remodeling processes during initial immobilization after injury.
PMID: 10025500 [PubMed - indexed for MEDLINE]
Considerations related to weight-bearing programs in children with developmental
disabilities.
Phys Ther. 1992 Jan;72(1):35-40.
Stuberg WA.
Meyer Rehabilitation Institute, University of Nebraska Medical Center, Omaha 68198-5450.
Standing is a common modality used in the management of children with developmental disabilities. The purpose
of this article is to examine the scientific basis for standing programs, with specific emphasis on the known
effects of weight bearing on bone development. Guidelines for the use of standing programs are presented, and
the supporting rationale is discussed.
PMID: 1728047 [PubMed - indexed for MEDLINE]
Page 53
Contractures secondary to immobility: is the restriction articular or muscular? An
experimental longitudinal study in the rat knee.
Arch Phys Med Rehabilitation. 2000 Jan;81(1):6-13.
Trudel G, Uhthoff HK.
Department of Medicine, University of Ottawa, Canada.
In 10 patients with spastic paraparesis, the effect of long-term stretch on hip adductor muscle tone was studied.
Stretch was accomplished by using a mechanical leg-abductor device giving individually adjusted adductor muscle
stretch in single or repeated 30 min periods. The effect on muscle tone was estimated from surface EMG activity
and by range of voluntary and passive hip abduction. The passive movements were obtained by an individually
adjusted constant pulling force. After a single session of stretch, range of voluntary hip abduction increased 3 to
16 degrees (average 85%). Range of passive movement increased 1 to 9 degrees (average 23%). After repeated
stretch periods in a home program (4 patients), range of voluntary hip abduction increased 5 to 22 degrees (average 255%). Range of passive movements increased 6 to 12 degrees (average 48%). In all patients studied the coactivation of the antagonists in voluntary hip abduction was reduced after a stretch session.
PMID: 10638868 [PubMed - indexed for MEDLINE]
Effects of a dynamic versus a static prone stander on bone material density and
behavior in four children with severe cerebral palsy.
PURPOSE: in this case series, we examined how two types of prone standers affected bone material density and
behavioral variables in four children of preschool age with severe cerebral palsy. METHODS: In phase one, four
children of preschool age participated in an eight-week standing program, standing for 30 minutes a day, five days
a week. Two children stood in a conventional stander, and two stood in a new type of motorized (dynamic)
stander that provides intermittent weight bearing. Measurements of bone material density before and after the
program revealed increases in bone material density in both children who used a dynamic stander and one child
who used a static stander. In phase two, all four subjects stood in both types of stander during three separate test
sessions. RESULT: Measures of behavioral variables, including behavioral state, reactivity, goal directedness, and
attention span, indicated little or no effect of type of stander on behavior. CONCLUSIONS: These results suggest
there is potential value in additional research concerning the effects of static and dynamic standers on bone
material density and behavior in children with cerebral palsy.
PMID: 17053680 [PubMed - in process]
Page 54
Research Studies
Pediatric Physical Therapy 2002;14:38-46.
Bjorg Gudjonsdottir, MS, PT, Vicki Stemmons Mercer, PhD, PT
Division of Physical Therapy, University of North Carolina at Chapel Hill, Chapel Hill, NC
Research Studies
Abstracts
Effects of a single session of prolonged muscle stretch on spastic muscle of stroke
patients.
Proc Natl SCI Counc Repub China B. 2001 Apr;25(2):76-81.
Tsai KH, Yeh CY, Chang HY, Chen JJ.
Department of Industrial Management, Southern Taiwan University of Technology, Tainan, ROC.
The control of spasticity is often a significant problem in the management of patients with spasticity. The aim of
this study was to evaluate the effect of a single session of prolonged muscle stretch (PMS) on the spastic muscle.
Seventeen patients with spastic hemiplegia were selected to receive treatment. Subjects underwent PMS of the
triceps surae (TS) by standing with the feet dorsiflexed on a tilt-table for 30 minutes. Our test battery consisted of
four measurements including the modified Ashworth scale of the TS, the passive range of motion (ROM) of ankle
dorsiflexion, the H/M ratio of the TS, and the F/M ratio of the tibialis anterior (TA). The results indicated that the
passive ROM of ankle dorsiflexion increased significantly (p < 0.05) compared to that before PMS treatment.
Additionally, PMS reduced motor neuron excitability of the TS and significantly increased that of the TA (p < 0.05).
These results suggest that 30 minutes of PMS is effective in reducing motor neuron excitability of the TS in spastic
hemiplegia, thus providing a safe and economical method for treating stroke patients.
PMID: 11370763 [PubMed - indexed for MEDLINE]
Effects of prolonged muscle stretch on reflex and voluntary muscle activations in
children with spastic cerebral palsy.
Scand J Rehabilitation Medicine. 1990;22(4):171-80.
Tremblay F, Malouin F, Richards CL, Dumas F.
Neurobiology Laboratory, Faculty of Medicine, Laval University, Quebec, Canada.
We studied the short term effects of a single session of prolonged muscle stretch (PMS) on reflex and voluntary
muscle activations in 22 children with spastic cerebral palsy (CP) assigned to an experimental (n = 12) and a control group (n = 10). Children of the experimental group underwent PMS of the triceps surae (TS) by standing with
the feet dorsiflexed on a tilt-table for 30 min, whereas children of the control group were kept at rest. The effects
were determined by measuring the associated changes in torque and in electromyographic (EMG) activity of the
TS and tibialis anterior (TA) muscles during both passive ankle movements and maximal static voluntary contractions. The results indicate that PMS led to reduced spasticity in ankle muscles as demonstrated by the significant
reductions (p less than 0.05) of the neuromuscular responses (torque and EMG) to passive movement. These
inhibitory effects lasted up to 35 min after cessation of PMS. In addition, the capacity to voluntarily activate the
plantar flexors was significantly (p less than 0.05) increased post-PMS, but the capacity to activate the dorsiflexors
was apparently not affected. These findings suggest that repeated sessions of PMS may have beneficial effects in
the management of spasticity in children with CP.
PMID: 2263918 [PubMed - indexed for MEDLINE]
The effect of a weight-bearing physical activity program on bone mineral content and
estimated volumetric density in children with spastic cerebral palsy.
J Pediatr 1999 Jul;135(1):115-7.
Chad KE, Bailey DA, McKay HA, Zello GA, Snyder RE.
College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
After an 8-month physical activity intervention in children with cerebral palsy, increases in femoral neck bone mineral content (BMC) (9.6%), volumetric bone mineral density (v BMD) (5.6%), and total proximal femur BMC (11.5%)
were observed in the intervention group (n = 9) compared with control subjects (n = 9; femoral neck BMC, -5. 8%;
v BMD, -6.3%; total proximal femur BMC, 3.5%).
PMID: 10393617 [PubMed - indexed for MEDLINE]
Page 55
Extent and direction of joint motion limitation after prolonged immobility: an
experimental study in the rat.
Arch Phys Med Rehabilitation. 1999 Dec;80(12):1542-7.
Trudel G, Uhthoff HK, Brown M.
Department of Medicine, University of Ottawa, and the Institute for Rehabilitation Research and Development,
Ontario, Canada.
PMID: 10597804 [PubMed - indexed for MEDLINE]
Evaluation of the effects of muscle stretch and weight load in patients with spastic
paraplegia.
Scand J Rehabilitation Medicine. 1981;13(4):117-21.
Odeen I, Knutsson E.
Clinical observations on patients with spastic paraplegia have indicated that a training regime including weight
load on the lower limbs may reduce the muscular hypertonus. Due to the spontaneous fluctuations and great variability in muscle tone it is difficult to judge from clinical findings how the effects may be related to muscle stretch
and weight load. Therefore, quantitative determination of the effects on muscle tone by stretch and loading was
made in 9 paraplegic patients. Muscle tone was measured before and after 30 min of stretch or weight load in 8
sessions on 4 consecutive days. Stretch was obtained by bracing the foot in maximal dorsal flexion with patient in
supine position. For weight load on the lower limbs, the patient stood on a tilt-table at an angle of 85 degrees
with feet in 15 degrees dorsal or plantar flexion. Resistance to passive movements was determined during a
series of sinusoidal ankle joint movements at three different speeds. After weight load in standing with the feet in
dorsal or plantar flexion, the average reduction was 32 and 26%, respectively. After stretch in supine, the average
reduction was 17%. Thus, the three procedures tested all resulted in reduction of muscle tone. The largest reductions were obtained by weight load with stretch imposed upon the calf muscles.
PMID: 7347432 [PubMed - indexed for MEDLINE]
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Research Studies
OBJECTIVES: To test the hypotheses that contractures progress at different rates in relation to the time after
immobilization, that immobilization in flexion leads to loss of extension range of motion, and that joints of shamoperated animals are better controls than the contralateral joint of experimental animals. STUDY DESIGN:
Experimental, controlled study in which 40 adult rats had one knee joint immobilized at 135 degrees of flexion for
up to 32 weeks and 20 animals underwent a sham procedure. At intervals of 2, 4, 8, 16, and 32 weeks, 8 experimental and 4 sham-operated animals were killed and their knee motion measured in flexion and extension.
RESULTS: In the experimental group, the range of motion decreased in the first 16 weeks of immobility at an average rate of 3.8 degrees per week (p<.0001) to reach 61.1 degrees of restriction. A plateau was then observed
from which the contracture did not progress further. The loss in range of motion occurred in extension, not in flexion. CONCLUSION: This study defined an acute stage of contractures starting at the onset of immobility and lasting
16 weeks, during which the range of motion was progressively restricted, and a chronic stage during which no
additional limitation was detected. The loss in motion was attributed to posterior knee structures not under tension during immobilization in flexion. Contrary to the hypothesis, the contralateral joint was validated as a control
choice for range-of-motion experiments.
Research Studies
Abstracts
Follow-up assessment of standing mobility device users.
Assistive Technology. 1998;10(2):84-93.
Dunn RB, Walter JS, Lucero Y, Weaver F, Langbein E, Fehr L, Johnson P, Riedy L.
Rehabilitation Research & Development Center, Edward Hines Jr. Veterans Affairs Hospital, Illinois 60141, USA.
The use of standing devices by spinal cord-injured subjects was investigated through a national survey of a sample of individuals who returned their manufacturer's warranty card to two companies. We obtained a 32%
response rate (99/310). The majority of respondents were male (87%) with a median age between 41 and 50
years. Seventy-seven percent were paraplegic and 21% were quadriplegic. Forty percent had between 1 and 5
years experience with their device, and 84% of those responding were currently using their standing device. Fortyone percent used their standing device one to six times a week; two-thirds stood between 30 minutes and 1 hour
for each use. Less than 10% of subjects experienced any side effects, such as nausea or headaches, from standing. Twenty-one percent of subjects reported being able to empty their bladder more completely. There was also a
favorable response by some individuals on the effects of the standing devices on bowel regularity, reduction of
urinary tract infections, leg spasticity, and number of bedsores. Finally, 79% of subjects highly recommended use
of standing devices to other people with spinal cord injury. The positive responses of individuals using standing
devices is a strong recommendation for the assistive technology community to make these devices more available to individuals with spinal cord injury.
PMID: 10339284 [PubMed - indexed for MEDLINE]
Hypokinesia-induced negative net calcium balance reversed by weight-bearing exercise.
Aviat Space Environ Med. 1987 Apr;58(4):308-14.
Lutz J, Chen F, Kasper CE.
Negative calcium balance and bone loss occurring with immobilization and hypokinesia have been attributed to a
lack of weight bearing on bones. The effects of weight-bearing exercise for promotion of calcium balance after
hypokinesia were examined. Rats were randomly assigned to either hypokinetic suspension for 28 d or to a control sedentary group, free to move about their cages at will. After 28 d, the rats in each group were randomly subdivided to either post-hypokinetic forced running (HR), post-hypokinetic sedentary (HS), control forced running
(CR), or control sedentary (CS) groups. Net calcium balance was then determined for 25 consecutive days. Net calcium balance of HR was negative for the first 5-d period of recovery and then became positive; that of HS was
negative for 25 d; that of CR and CS remained essentially positive. Net calcium absorption paralleled net calcium
balance. Forced running was effective in reestablishment of positive net calcium balance after 28 d of decreased
weight bearing.
PMID: 3579816 [PubMed - indexed for MEDLINE]
Indications for a home standing program for individuals with spinal cord injury.
J Spinal Cord Med. 1999 Fall;22(3):152-8.
Walter JS, Sola PG, Sacks J, Lucero Y, Langbein E, Weaver F.
Edward Hines Jr. Veterans Affairs Hospital Research Service (151L), Hines, IL 60141, USA.
Additional analyses were conducted on a recently published survey of persons with spinal cord injury (SCI) who
used standing mobility devices. Frequency and duration of standing were examined in relation to outcomes using
chi square analyses. Respondents (n = 99) who stood 30 minutes or more per day had significantly improved quality of life, fewer bed sores, fewer bladder infections, improved bowel regularity, and improved ability to straighten
their legs compared with those who stood less time. Compliance with regular home standing (at least once per
week) was high (74%). The data also suggest that individuals with SCI could benefit from standing even if they
were to begin several years after injury. The observation of patient benefits and high compliance rates suggest
that mobile standing devices should be more strongly considered as a major intervention for relief from secondary medical complications and improvement in overall quality of life of individuals with SCI.
PMID: 10685379 [PubMed - indexed for MEDLINE]
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The influence of activity on calcium metabolism.
J Nutr Sci Vitaminol (Tokyo). 1985 Dec;31 Suppl:S41-4.
Whedon GD.
Many studies and observations have shown the bone-losing effects of physical inactivity of various forms.
Contrariwise, less precise studies and observations have supported the reasonable premise that mechanical loading of the skeleton via physical activity shifts the balance of bone remodeling in favor of bone formation, and
appears to do so at all ages. Some interesting starts have been made in research to discover the mechanisms of
the action on bone of mechanical loading, but many pathways remain to be explored. Besides the mechanical
forces, we need to know more about the interrelations of muscle function, probably mediated through muscletendon pull on periosteum, and more about other likely influences, notably changes in circulation to bones. The
practical significance relative to calcium metabolism and aging of what has been learned thus far on the effects of
activity, is that prolonged inactivity, either in a chair or in bed, is to be avoided, because of its deleterious effects,
and that reasonably energetic gravitational exercise, such as walking or possibly jogging, promotes maintenance
of bone health.
PMID: 3915756 [PubMed - indexed for MEDLINE]
Arch Phys Med Rehabilitation. 1999 Nov;80(11):1402-10.
McKinley WO, Jackson AB, Cardenas DD, DeVivo MJ.
Department of Physical Medicine & Rehabilitation, Medical College of Virginia/Virginia Commonwealth University,
Richmond 23298, USA.
OBJECTIVE: To analyze the incidence, risk factors, and trends of long-term secondary medical complications in
individuals with traumatic spinal cord injury. DESIGN: Data were reviewed from the National SCI Statistical Center
on annual evaluations performed at 1, 2, 5, 10, 15, and 20 years after injury on patients injured between 1973 and
1998. SETTING: Multicenter Regional SCI Model Systems. MAIN OUTCOME MEASURES: Secondary medical complications at annual follow-up years, including pneumonia/atelectasis, autonomic dysreflexia, deep venous thrombosis, pulmonary embolism, pressure ulcers, fractures, and renal calculi. RESULTS: Pressure ulcers were the most
frequent secondary medical complications in all years, and individuals at significant (p < .05) risk included those
with complete injuries (years 1, 2, 5, 10), younger age (year 2), concomitant pneumonia/atelectasis (year 1, 2, 5),
and violent injury (years 1, 2, 5, 10). The incidence of pneumonia/atelectasis was 3.4% between rehabilitation discharge and year-1 follow-up with those most significantly at risk being older than 60 years (years 1, 2, 5, 10) and
tetraplegia-complete (years 1, 2). One-year incidence of deep venous thrombosis was 2.1% with a significant
decline seen at year 2 (1.2%), and individuals most significantly (p < .001) at risk were those with complete
injuries (year 1). The incidence of calculi (kidney and/or ureter) was 1.5% at 1-year follow-up and 1.9% at 5 years
and was more frequent in patients with complete tetraplegia. Intermittent catheterization was the most common
method of bladder management among patients with paraplegia but became less common at later postinjury visits. CONCLUSIONS: Pressure ulcers, autonomic dysreflexia, and pneumonia/atelectasis were the most common
long-term secondary medical complications found at annual follow-ups. Risk factors included complete injury,
tetraplegia, older age, concomitant illness, and violent injury.
PMID: 10569434 [PubMed - indexed for MEDLINE]
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Research Studies
Long-term medical complications after traumatic spinal cord injury: a regional model
systems analysis.
Research Studies
Abstracts
Low magnitude mechanical loading is osteogenic in children with disabling conditions.
J Bone Miner Res. 2004 Mar;19(3):360-9. Epub 2004 Jan 27. Links
Ward K, Alsop C, Caulton J, Rubin C, Adams J, Mughal Z.
Clinical Radiology, Imaging Science & Biomedical Engineering, University of Manchester, Manchester, United
Kingdom.
The osteogenic potential of short durations of low-level mechanical stimuli was examined in children with disabling conditions. The mean change in tibia vTBMD was +6.3% in the intervention group compared with -11.9% in
the control group. This pilot randomized controlled trial provides preliminary evidence that low-level mechanical
stimuli represent a noninvasive, non-pharmacological treatment of low BMD in children with disabling conditions.
INTRODUCTION: Recent animal studies have demonstrated the anabolic potential of low-magnitude, high-frequency mechanical stimuli to the trabecular bone of weight-bearing regions of the skeleton. The main aim of this
prospective, double-blind, randomized placebo-controlled pilot trial (RCT) was to examine whether these signals
could effectively increase tibial and spinal volumetric trabecular BMD (vTBMD; mg/ml) in children with disabling
conditions. MATERIALS AND METHODS: Twenty pre-or postpubertal disabled, ambulant, children (14 males, 6
females; mean age, 9.1 +/- 4.3 years; range, 4-19 years) were randomized to standing on active (n = 10; 0.3g, 90
Hz) or placebo (n = 10) devices for 10 minutes/day, 5 days/week for 6 months. The primary outcomes of the trial
were proximal tibial and spinal (L2) vTBMD (mg/ml), measured using 3-D QCT. Posthoc analyses were performed to
determine whether the treatment had an effect on diaphyseal cortical bone and muscle parameters. RESULTS
AND CONCLUSIONS: Compliance was 44% (4.4 minutes per day), as determined by mean time on treatment (567.9
minutes) compared with expected time on treatment over the 6 months (1300 minutes). After 6 months, the
mean change in proximal tibial vTBMD in children who stood on active devices was 6.27 mg/ml (+6.3%); in children who stood on placebo devices, vTBMD decreased by -9.45 mg/ml (-11.9%). Thus, the net benefit of treatment
was +15.72 mg/ml (17.7%; p = 0.0033). In the spine, the net benefit of treatment, compared with placebo, was
+6.72 mg/ml, (p = 0.14). Diaphyseal bone and muscle parameters did not show a response to treatment. The
results of this pilot RCT have shown for the first time that low-magnitude, high-frequency mechanical stimuli are
anabolic to trabecular bone in children, possibly by providing a surrogate for suppressed muscular activity in the
disabled. Over the course of a longer treatment period, harnessing bone's sensitivity to these stimuli may provide
a non-pharmacological treatment for bone fragility in children.
PMID: 15040823 [PubMed - indexed for MEDLINE]
Mobility status and bone density in cerebral palsy.
Wilmshurst S, Ward K, Adams JE, Langton CM, Mughal MZ.
Arch Dis Child. 1996 Aug;75(2):164-5.
Department of Pediatrics, St Mary's Hospital, Manchester.
The spinal bone mineral density (SBMD) and calcaneal broadband ultrasound attenuation (BUA) was
measured in 27 children with cerebral palsy. They were categorised into four mobility groups: mobile with an
abnormal gait, mobile with assistance, non-mobile but weight bearing, non-mobile or weight bearing. Mean SD
scores for BUA and SBMD differed among mobility groups (analysis of variance, p < 0.001 and p = 0.078, respectively).
PMID: 8869203 [PubMed - indexed for MEDLINE]
Nonoperative treatment of osteogenesis imperfecta: orthotic and mobility
management.
Clin Orthop Relat Res. 1981 Sep;(159):111-22.
Bleck EE.
The problem of osteoporosis superimposed on the basic collagen defect of osteogenesis imperfecta has been
approached by the use of plastic containment orthoses for the lower limbs, in addition to developmentally staged
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mobility devices that assist early standing and walking. The purpose of forcing early weight-bearing is to provide
stress to the lower limb bones in order to minimize osteoporosis, prevent refracture and deformity, and curb subsequent immobilization osteoporosis, thus breaking a vicious cycle. Management goals are based upon adult
needs for independence: efficiency in daily living activities and in mobility. These goals were reached in most of
our patients via use of plastic orthoses, early weight-bearing, and electrically powered wheelchairs. Manual osteoclasis of the tibia followed by plastic orthoses utilizing principles of fluid compression to support fractured or
structurally weak bones appeared successful at the time of follow-up. Intramedullary rodding of the femur was
necessary in most of the 12 children with osteogenesis imperfecta congenita. Supplementary plastic orthoses
have reduced the refracture rate in both the tibia and the femur. Social integration of the children was reflected
by the fact that among the 12 OI congenita cases, ten were attending regular educational institutions. Twelve OI
tarda children fared well, all attaining complete independence in daily living, mobility and ambulation. Seven of
this group were treated with intramedullary rodding of the femur or tibia and with plastic orthoses. Five patients
required no treatment.
PMID: 7285447 [PubMed - indexed for MEDLINE]
Osteogenesis imperfecta: rehabilitation approach with infants and young children.
Arch Phys Med Rehabilitation. 1984 Sep;65(9):537-41.
Binder H, Hawks L, Graybill G, Gerber NL, Weintrob JC.
PMID: 6477088 [PubMed - indexed for MEDLINE]
Osteoporosis, calcium and physical activity.
CMAJ. 1987 Mar 15;136(6):587-93.
Martin AD, Houston CS.
Sales of calcium supplements have increased dramatically since 1983, as middle-aged women seek to prevent or
treat bone loss due to osteoporosis. However, epidemiologic studies have failed to support the hypothesis that
larger amounts of calcium are associated with increased bone density or a decreased incidence of fractures. The
authors examine the evidence from controlled trials on the effects of calcium supplementation and physical activity on bone loss and find that weight-bearing activity, if undertaken early in life and on a regular basis, can
increase the peak bone mass of early adulthood, delay the onset of bone loss and reduce the rate of loss. All of
these factors will delay the onset of fractures. Carefully planned and supervised physical activity programs can
also provide a safe, effective therapy for people who have osteoporosis.
PMID: 3545420 [PubMed - indexed for MEDLINE]
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Research Studies
A rehabilitation approach, consisting of initial handling and positioning followed by functional and formal strengthening exercises, was developed for the child with severe progressive osteogenesis imperfecta (OI). The program
was developed because of the increased life expectancy for infants and children with severe progressive OI, combined with the lack of published reports dealing with their rehabilitation. The program can be followed easily by
parents or therapists with regular monitoring by a psychiatrist. The goals are to improve the life span as well as
the quality of life of these children by preventing the following: (1) positional contractures and deformities, (2)
muscle weakness and osteoporosis, and (3) malalignment of the lower extremity joints prohibiting weight-bearing.
Implementation of the program requires full cooperation of the parents. The initial results in four children between
the ages of 3 and 11 years are encouraging. The benefits of increased strength and mobility leading to more ageappropriate activities and behaviors outweigh the only observed negative result, that is trauma-related lower
extremity fractures in children with milder disease, and therefore greater mobility and higher activity levels.
Research Studies
Abstracts
Pathological fractures in patients with cerebral palsy.
J Pediatr Orthop B. 1996 Fall;5(4):232-8.
Comment in: J Pediatr Orthop B. 1996 Fall;5(4):223-4.
Brunner R, Doderlein L.
Department of Paediatric Orthopaedics, University of Basel, Switzerland.
A retrospective study was made of 37 patients with 54 fractures that occurred without significant trauma. The
morbidity and causes of these pathological fractures in patients with cerebral palsy were analyzed. The major
causes for the fractures were long and fragile lever arms and stiffness in major joints, particularly the hips and
knees. An additional factor was severe osteoporosis following a long period of postoperative immobilization.
Seventy-four percent of the fractures occurred in the femoral shaft and supracondylar region. Stress fractures
were rare (7%) and involved only the patella. Conservative treatment was sufficient in most cases but surgical fixation provided a good alternative for fractures of the femoral shaft. Intraarticular fractures with joint incongruity
resulted in a decreased level of activity of the patient. Since osteoporosis is a major risk factor, patients with cerebral palsy should bear weight to prevent pathological fractures. Any stiffness of major joints and extended periods
of immobilization should be avoided.
PMID: 8897254 [PubMed - indexed for MEDLINE]
Reduction of muscular hypertonus by long-term muscle stretch.
Scand J Rehabilitation Medicine. 1981;13(2-3):93-9.
Odeen I, Knutsson E.
In 10 patients with spastic paraparesis, the effect of long-term stretch on hip adductor muscle tone was studied.
Stretch was accomplished by using a mechanical leg-abductor device giving individually adjusted adductor muscle
stretch in single or repeated 30 min periods. The effect on muscle tone was estimated from surface EMG activity
and by range of voluntary and passive hip abduction. The passive movements were obtained by an individually
adjusted constant pulling force. After a single session of stretch, range of voluntary hip abduction increased 3 to
16 degrees (average 85%). Range of passive movement increased 1 to 9 degrees (average 23%). After repeated
stretch periods in a home program (4 patients), range of voluntary hip abduction increased 5 to 22 degrees (average 255%). Range of passive movements increased 6 to 12 degrees (average 48%). In all patients studied the coactivation of the antagonists in voluntary hip abduction was reduced after a stretch session.
PMID: 7345572 [PubMed - indexed for MEDLINE]
Reliability and comparison of weight-bearing ability during standing tasks for individuals with chronic stroke.
Arch Phys Med Rehabilitation. 2002 Aug;83(8):1138-44.
Eng JJ, Chu KS.
School of Rehabilitation Sciences, University of British Columbia, Vancouver, BC, Canada.
[email protected]
OBJECTIVES: To determine the test-retest reliability over 2 separate days for weight-bearing ability during standing
tasks in individuals with chronic stroke and to compare the weight-bearing ability among 5 standing tasks for the
paretic and nonparetic limbs. DESIGN: Prospective study using a convenient sample. SETTING: Free-standing tertiary rehabilitation center. PARTICIPANTS: Fifteen community-dwelling stroke individuals with moderate motor
deficits; volunteer sample. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Weight-bearing ability as
measured by the vertical ground reaction force during 5 standing tasks (rising from a chair, quiet standing, weightshifting forward, backward, laterally). RESULTS: The weight-bearing ability was less for the paretic limb compared
with the nonparetic limb, but the intraclass correlation coefficients were high (.95-.99) for both limbs between the
2 sessions for all 5 tasks. The forward weight-shifting ability was particularly low in magnitude on the paretic side
compared with the other weight-shifting tasks. In addition, the forward weight-shift ability of the nonparetic limb
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was also impaired but to a lesser extent. Large asymmetry was evident when rising from a chair, with the paretic
limb bearing a mean 296N and the nonparetic side bearing a mean 458N. The weight-bearing ability during all 5
tasks correlated with one another (r range,.56-.94). CONCLUSIONS: Weight-bearing ability can be reliably measured
and may serve as a useful outcome measure in individuals with stroke. We suggest that impairments of the hemiparetic side during forward weight shifting and sit-to-stand tasks presents a challenge to the motor systems of
individuals with stroke, which may account for the poor balance that is often observed in these individuals.
Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical
Medicine and Rehabilitation.femur or tibia and with plastic orthoses. Five patients required no treatment.
PMID: 12161837 [PubMed - indexed for MEDLINE]
Skeletal cell stresses and bone adaptation.
Am J Med Sci. 1998 Sep;316(3):176-83.
McLeod KJ, Rubin CT, Otter MW, Qin YX.
Musculoskeletal Research Laboratory, Health Sciences Center, State University of New York, Stony Brook 117948181, USA. [email protected]
PMID: 9749559 [PubMed - indexed for MEDLINE]
Standing and its importance in spinal cord injury management.
RESNA 10th Annual Conference San Jose, California 1987
Axelson P, Gurski D, Lasko-Harvill A.
IMEX Inc. San Jose, California
Beneficial Designs, Inc., Santa Cruz, California
A broad spectrum of physiological problems are associated with lack of gravitational stress in the individual with
spinal cord injury. Prolonged immobilization results in systemic de-adaptations which include cardiovascular
changes, the alteration of calcium homeostasis which leads to bone de-mineralization and risk of urinary calculi.
Weight bearing in the standing posture has been shown to ameliorate many of these problems and offers physiological advantages for the individual with spinal card injury. There are also significant psychological and social benefits to standing, including improved self-image, and eye-to-eye interpersonal contact. Increased vocational, recreational and daily living independence are additional benefits of standing.
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Research Studies
There is no tissue in which mechanical stresses have been studied in more detail than the skeletal system, this
focus arising primarily because bone plays a clear structural role in the body. However, the hypothesis that the
skeleton represents an optimally designed structure has contributed remarkably little to our understanding of the
development and adaptive capabilities of bone tissue. Recent investigations on the consequences of mechanical,
hydrostatic, and electrical stresses on the cells of bone tissue have served to redirect the discussion of bone
modeling and remodeling processes. These studies have refocused attention on the importance of chronic lowlevel dynamic stresses in mediating the physiologic response of bone tissue. Important recent observations suggest that an approach premised on the self-organizational properties of bone tissue may lead to significant
improvements in our understanding and control of bone morphologic development, adaptation, and healing.
Research Studies
Abstracts
Tilt table standing for reducing spasticity after spinal cord injury.
Arch Physical Medicine Rehabilitation. 1993 Oct;74(10):1121-2.
Bohannon RW.
Department of Rehabilitation, Hartford Hospital, CT.
A patient with a T12 spinal cord injury and intractable extensor spasms of the lower extremities participated in tilt
table standing trial on 5 nonconsecutive days to determine if the intervention would affect his spasticity and
spasms. Each day's standing trial was followed by an immediate reduction in lower extremity spasticity (measured using the modified Ashworth scale and pendulum testing). Standing was also accompanied by a reduction
in spasms that lasted until the following morning. The reduction of spasms was particularly advantageous to the
performance of car transfers. Tilt table standing merits further examination as a physical treatment of spasms that
accompany central nervous system lesions.
PMID: 8215868 [PubMed - indexed for MEDLINE]
Use of prolonged standing for individuals with spinal cord injuries.
Phys Ther. 2001 Aug;81(8):1392-9.
Eng JJ, Levins SM, Townson AF, Mah-Jones D, Bremner J, Huston G.
School of Rehabilitation Sciences, University of British Columbia, T325-2211 Wesbrook Mall, Vancouver, British
Columbia, Canada V6T [email protected]
BACKGROUND AND PURPOSE: Prolonged standing in people with spinal cord injuries (SCIs) has the
potential to affect a number of health-related areas such as reflex activity, joint range of motion, or well-being.
The purpose of this study was to document the patterns of use of prolonged standing and their perceived effects
in subjects with SCIs. SUBJECTS: The subjects were 152 adults with SCIs (103 male, 49 female; mean age=34
years, SD=8, range=18-55) who returned mailed survey questionnaires. METHODS: A 17-item self-report survey
questionnaire was sent to the 463 members of a provincial spinal cord support organization. RESULTS: Survey
responses for 26 of the 152 respondents were eliminated from the analysis because they had minimal effects
from their injuries and did not need prolonged standing as an extra activity. Of the 126 remaining respondents, 38
respondents (30%) reported that they engaged in prolonged standing for an average of 40 minutes per session, 3
to 4 times a week, as a method to improve or maintain their health. The perceived benefits included improvements in several health-related areas such as well-being, circulation, skin integrity, reflex activity, bowel and bladder function, digestion, sleep, pain, and fatigue. The most common reason that prevented the respondents from
standing was the cost of equipment to enable standing. DISCUSSION AND CONCLUSION: Considering the many
reported benefits of standing, this activity may be useful for people with SCI. This study identified a number of
body systems and functions that may need to be investigated if clinical trials of prolonged standing in people with
SCI are undertaken.
PMID: 11509069 [PubMed - indexed for MEDLINE]
The vertical wheeler: a device for ambulation in cerebral palsy.
Arch Phys Med Rehabilitation. 1985 Oct;66(10):717-20.Links
The vertical wheeler: a device for ambulation in cerebral palsy.Manley MT, Gurtowski J.
The vertical wheeler is a new mobility aid that was specifically designed to help improve the quality of life for the
handicapped child by providing mobility while standing. Results of a clinical trial in a population of patients with
cerebral palsy are presented. Criteria were selected to allow evaluation of the rehabilitative effect of the device
on the population. Results showed that the children in this cerebral palsy group all benefited from ambulation
with the wheeler. Patients with spastic quadriparesis seemed to gain the most immediate benefit. The device contributed to improved mobility, posture, and self-image. The wheeler was safe and fun for the children. It has the
potential for improving the psychologic and medical status of the child with severe locomotion impairment.
PMID: 4051716 [PubMed - indexed for MEDLINE]
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Weight-bearing exercise training and lumbar bone mineral content in postmenopausal
women.
Ann Intern Med. 1988 Jun;108(6):824-8.
Dalsky GP, Stocke KS, Ehsani AA, Slatopolsky E, Lee WC, Birge SJ.
Washington University School of Medicine, St. Louis, Missouri.
PMID: 3259410 [PubMed - indexed for MEDLINE]
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Research Studies
STUDY OBJECTIVE: To assess the effect of weight-bearing exercise training and subsequent detraining on lumbar
bone mineral content in postmenopausal women. DESIGN: Non-randomized, controlled, short-term (9 months) trial
and long-term (22 months) exercise training and detraining (13 months). SETTING: Section of applied physiology at
a university school of medicine. PATIENTS: Thirty-five healthy, sedentary postmenopausal women, 55 to 70 years
old. All women completed the study. There was 90% compliance with exercise training. INTERVENTIONS: All
women were given calcium, 1500 mg daily. The exercise group did weight-bearing exercise (walking, jogging, stair
climbing) at 70% to 90% of maximal oxygen uptake capacity for 50 to 60 min, 3 times weekly. MEASUREMENTS
AND MAIN RESULTS: Bone mineral content increased 5.2% (95% confidence interval [CI], 2.0% to 8.4%; P = 0.0037)
above baseline after short-term training whereas there was no change (-1.4%) in the control group. After 22
months of exercise, bone mineral content was 6.1% (95% CI, 3.9% to 8.3% above baseline; P = 0.0001) in the longterm training group. After 13 months of decreased activity, bone mass was 1.1% above baseline in the detraining
group. CONCLUSIONS: Weight-bearing exercise led to significant increases above baseline in bone mineral content
which were maintained with continued training in older, postmenopausal women. With reduced weight-bearing
exercise, bone mass reverted to baseline levels. Further studies are needed to determine the threshold exercise
prescription that will produce significant increases in bone mass.
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Altimate Medical, Inc. - makers of EasyStand products ©2007
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Altimate Medical, Inc. - makers of EasyStand products ©2007
Legal Services & Resources
Legal Services
The Consumer’s Appeal Process
Standing Technology
Occasionally, payer sources do not see eye to eye with the consumer’s medical needs. Altimate
Medical is here to help guide you, the consumer, through the appeals process.
Medical Assistance/Medicaid
1. Don’t take “No” for an answer. Appeal if denied!
2. Start by reviewing the documentation that was submitted.
• Was it complete? For example, does it include the trial process and the individual’s
specific medical needs?
• If you are not comfortable reviewing the letter of medical necessity yourself, you can
fax (952-937-0821) or email ([email protected]) us and we would be happy to
assist with review.
• If further documentation is needed, go to your clinician for help. Photos and/or videos
may help convey the information.
3. Request an appeal in writing. This written request must be received by the department within
a specified time frame, usually 0-90 days (check with your state). Make sure to send a copy of
the Medicaid notice of denial with the appeal letter. The notice includes needed information
such as recipient’s name, address, and ID number. Be sure to keep a copy of both the letter and
the notice of denial.
4. An appeals referee will be assigned to hear your appeal. She or he may schedule a telephone
hearing. You have the right to an in-person hearing, which is usually preferable. You can, in
fact, state in your letter that the hearing be held in person.
5. Identify potential expert witnesses such as a speech-language Pathologist, an Occupational
Therapist, a Physical Therapist, a Psychiatrist, etc. In-person testimony is desirable; however, it
is acceptable to have testimony by phone or in a written letter.
6. It is helpful to have assistance from an advocate or attorney (see Legal Services &
Resources section). PAAT (Protection Advocacy for Assistive Technology) attorneys are a free
resource available to assist persons with disabilities and their families as they seek funding for
Assistive Technology (AT).
Private Insurance
1. Don’t take “No” for an answer. Appeal if denied!
2. Know the appeals process for your payer source by calling your payer source or checking in
your policy manual. Generally, there are four types of insurance that may be funding resources
for Assistive Technology.
• Health Insurance
• Disability Insurance
• Worker’s Compensation
• Liability Insurance
3. The process and criteria may vary among insurance policies; most, however will specify
a process similar to Medical Assistance/Medicaid’s prior authorization and appeal process (see
above).
Page 79
Some information provided by the Minnesota Disability Law Center, Legal Advocacy for Persons with Developmental Disabilities. Minneapolis Office 612-332-1441
PAAT & AT Project Directory
Sources of Funding Assistance and Information
P A A T - http://www.nls.org/natmain.htm
The National Assistive Technology Advocacy Project supports the advocacy efforts of attorneys, advocates, service agencies, persons
with disabilities and their families as they seek funding for assistive technology.
A T P r o j e c t - http://www.resna.org/taproject/at/statecontacts.html
Each state in the U.S. has a Technology Assistance project that has up to date information on assistive technology resources for that
state. Some projects have compiled lists of funding resources available in their states.
ALABAMA-PAAT
AMERICAN SAMOA-PAAT
Alabama Disabilities Advocacy Program
P.O. Box 870395
Tuscaloosa, AL 35487-0395
Tel: (205) 348-4928
Fax: (205) 348-3909
Website: www.adap.net
email: [email protected]
David Gamble, Case Advocate
American Samoa P&A
PO Box 3937
Pago Pago, AS 96799
Tel: (011-684) 633-2441
Fax: (011-684) 633-7286
Mane Togaloa, Program Manager
email: [email protected]
Marie Mao, Director
ALABAMA-AT Project
AMERICAN SAMOA-AT Project
Statewide Technology Access and Response (STAR)
System for Alabamians with Disabilities
Alabama Dept. of Rehabilitation Services
2125 East South Blvd. P.O. Box 20752
Montgomery, AL 36120-0752
Tel: (334) 613-3519
Fax: (334) 613-3485
Executive Director: Frankie Mitchum
email: [email protected]
Website: www.rehab.state.al.us/star
American Samoa AT Service Project
Division of Vocational Rehabilitation
Dept. of Human Resources
Pago Pago, AS 96799
Tel: (011-684) 233-7874
Fax: (011-684) 699-1276
Project Director: Jack Potasi
email: [email protected]
ARIZONA-PAAT
Arizona Center for Disability Law
100 N. Stone Ave., Suite 305
Tucson, AZ 85701
Tel: (520) 327-9547
Fax: (520) 884-0992
Website: www.azdisabilitylaw.org
email: [email protected]
Henry Watkins, Executive Director
ALASKA-PAAT
Disability Law Center of Alaska
3330 Artic Blvd., Suite 103
Anchorage, Alaska 99503
800-478-1234 (toll free in Alaska)
907-565-1002 phone and tty
907-565-1000 fax
Website: www.dlcak.org
David Fleurant, Staff Attorney
email: [email protected]
ALASKA-AT Project
Alaska AT Project
Department of Labor & Workforce Development
Division of Vocational Rehabilitation
801 W. 10th Street, Suite A
Juneau, AK 99801
Tel: (800) 478-4378
Fax: (907) 269-3632
Program Coordinator: Sean O'Brien
Website: http://www.labor.state.ak.us/at/index.htm
email: [email protected]
Page 80
Reprinted with permission - Altimate Medical, Inc. - makers of EasyStand products ©2007
Legal Services &
Resources
Arizona Center for Disability Law
3839 N. 3rd Street, Suite 209
Phoenix, AZ 85012
Tel: (602) 274-6287
Fax: (602) 274-6779
Website: www.acdl.com
email: [email protected]
Natalie Franklin, Coordinator
ARIZONA-AT Project (cont)
CALIFORNIA-PAAT
Protection and Advocacy Inc.
3850 Wilshire Blvd Ste 902
Los Angeles CA 90010
Tel: (213) 427-8747
Website: www.pai-ca.org
e-mail: [email protected]
Melinda Bird, Attorney
Institute for Human Development
Northern Arizona University
2400 N. Central Avenue, Suite 300
Phoenix, AZ 85004
Tel: (602) 728-9534
Fax: (602) 728-9353
Director: Jill Sherman Pleasant
email: [email protected]
Website: http://www.nau.edu/ihd/aztap/
Protection and Advocacy Inc.
433 Hegenberger Road Ste 220
Oakland CA 94621
Tel: (510) 430-8033
Website: www.pai-ca.org
e-mail: [email protected]
Regina Kendricks, Attorney
ARKANSAS-PAAT
Disability Rights Center, Inc.
1100 N. University #201
Little Rock, AR 72207
Tel: (501) 296-1775
Fax: (501) 296-1779
Website: www.arkdisabilityrights.org
e-mail: [email protected]
Jan Baker, Attorney
CALIFORNIA-AT Project
California AT System
Dept. of Rehabilitation
2000 Evergreen P.O. Box 944222
Sacramento, CA 94244-2220
Tel: (916) 263-8685
Fax: (916) 263-8683
Project Director: Richard Devylder
e-mail: [email protected]
Website: www.atnet.org
ARKANSAS-AT Project
Arkansas Increasing Capabilities Access Network
Dept. of Education/Vocational Education Division
Arkansas Rehabilitation Services
2201 Brookwood Drive Ste. 117
Little Rock, AR 72202
Tel: (800) 828-2799
Fax: (501) 666-5319
Project Director: Barry Vuletich
e-mail: [email protected]
Website: www.arkansas-ican.org
COLORADO-PAAT
The Legal Center
2829 North Ave., Suite 205
Grand Junction, CO 81501-1501
Tel: (907) 241-6371
Fax: (970) 241-5324
Website: www.thelegalcenter.org
[email protected]
Sara Sharer
CALIFORNIA-PAAT
Protection and Advocacy Inc.
100 Howe Ave. Suite 235N
Sacramento, CA 95865
Tel: (916) 488-9950
Fax: (916) 488-9960
Website: www.pai-ca.org
e-mail: [email protected]
Attorney: Ann Coller
COLORADO-AT Project
Colorado AT Project
The Pavilion, A036/B140
1919 Ogden St
Denver, CO 80218
Tel: (303) 864-5110
Fax: (303) 864-5119
email: [email protected]
Website: www.uchsc.edu/atp
Protection and Advocacy Inc.
1111 Sixth Ave Ste 200
San Diego, CA 92101
Tel: (619) 239-7861
Fax: (619) 239-7906
Website: www.pai-ca.org
e-mail: [email protected]
Margaret Jakobson, Attorney
CONNECTICUT-PAAT
Office of P&A for Persons with Disabilities
60B Weston Street
Hartford, CT 06120-1551
Tel: (860) 297-4300
Fax: (860) 566-8714
Website: www.state.ct.us/opapd
email: [email protected]
Gretchen Knauff, Coordinator
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Reprinted with permission - Altimate Medical, Inc. - makers of EasyStand products ©2007
CONNECTICUT-AT Project (cont)
FLORIDA-PAAT
Connecticut AT Program
Dept. of Social Service
Bureau of Rehabilitation Services
25 Sigourney St 11th Floor
Hartford, CT 06106
Tel: (860) 424-4881
Fax: (860) 424-4850
Project Director: Dawn Lambert
email: [email protected]
Website: http://www.CTtechact.com
Advocacy Center for Persons w/Disabilities
2671 Executive Center Circle West, Suite 100
Tallahassee, FL 32301
Tel: (850) 488-9071
Fax: (850) 488-8640
www.advocacycenter.org
Gary Weston, Director
FLORIDA-AT Project
Florida Alliance for assistive Services and Technology
325 John Knox Road, Bldg. 400, Suite 402
Tallahassee, FL 32303-4151
Tel: (888) 788-9216
Fax: (850) 487-2805
email: [email protected]
Executive Director: Jane Johnson
Website: www.faast.org
DELAWARE-PAAT
Community Legal Aid Society, Inc.
Community Services Building, Suite 801
100 West 10th Street
Wilmington, DE 19801
Tel: (302) 575-0660
Fax: (302) 575-0840
email: [email protected]
Daniel G. Atkins, Legal Advocacy Director ext 229
email: [email protected]
Brian J. Hartman, Administrator ext 220
GEORGIA-PAAT
DELAWARE-AT Project
Delaware AT Initiative
Center for Applied Science and Engineering
University of Delaware/A.I. DuPont Hospital for Children
1600 Rockland Road Room 154
P.O. Box 269
Wilmington, DE 19899-0269
Tel: (302) 651-6790
Fax: (302) 651-6793
email: [email protected]
Website: http://www.dati.org
DISTRICT OF COLUMBIA-PAAT
University Legal Services/P&A
220 I Street, N.E. Suite 130
Washington, D.C. 20002
Tel: (202) 547-0198
Fax: (202) 547-2662
Website: www.dcpanda.org
email: [email protected]
Sandy Bernstein, Legal Director
email: [email protected]
Alicia Johns, AT Program Manager ext134
GEORGIA-AT Project
Tools for Life
Georgia Department of Labor
Vocational Rehabilitation Program
Assistive Technology Unit
1700 Century Circle, Suite 300
Atlanta, GA 30345
Tel: (404) 638-0384
Fax: (404) 486-0218
email: [email protected]
Program Manager: Carolyn Phillips
Website: www.gatfl.org
GUAM-PAAT
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Legal Services &
Resources
Guam Legal Services Corp.
113 Bradley Pl
Hagatna, GU 96910-4911
Tel: (671) 477-9811
Fax: (671) 477-1320
email: [email protected]
Theresa Ceoeda, Administrator
Dan Somerfleck, Director
DISTRICT OF COLUMBIA-AT Project
University Legal Service AT Program for the
District of Columbia
220 I Street, NE, Suite 130
Washington, DC 20002
Tel: (202) 547-0198
Fax: (202) 547-2662
email: [email protected]
Program Manager: Alicia C. Johns
Website: http://www.atpdc.org
Georgia Advocacy Office
1 Decatur Town Ctr, Bldg 150, East Ponce de Leon, Ste 430
Decatur, GA 30030
Tel: (404) 885-1234
Fax: (770) 378-0031
Website: www.thegao.org
email: [email protected]
Naomi Walker, Attorney
GUAM-AT Project (cont)
ILLINOIS-PAAT
Guam System for AT
University of Guam
University of Affiliated Program on Development Disabilities
UOG Station
303 University Drive, House #19 Dean’s Circle
Mangiao, GU 96923
Tel: (011-671) 735-2490
Fax: (010-671) 734-8378
email: [email protected]
Website: http://www.uog.edu/cedders/gsat.htm
Equip for Equality Inc (Northwestern)
1617 Second Ave Ste 210
Rock Island IL 61204
Tel: (309) 786-6868
Fax: (309) 786-2393
www.equipforequality.org
email: [email protected]
Janet Cartwright, Attorney
HAWAII-PAAT
Hawaii Disability Rights Center
900 Fort St Mall Ste 1040
Honolulu, HI 96813
Tel: (808) 949-2922 ext. 207
Fax: (808) 949-2928
email: [email protected]
Gary Smith, Director
Website: www.hawaiidisabilityrights.org
Equip for Equality Inc (Chicago)
20 N. Michigan Avenue, Suite 300
Chicago, IL 60602
Tel: (312) 341-0022
Fax: (312) 341-0295
www.equipforequality.org
email: [email protected]
Amy Peterson, Senior Attorney
ILLINOIS-PAAT
Equip for Equality Inc (Central/Southern)
235 S. Fifth Street, P.O. Box 276
Springfield, IL 62705
Tel: (217) 544-0464
Fax: (217) 523-0720
www.equipforequality.org
Barry G. Lowy, Senior Attorney
HAWAII-AT Project
AT Resource Centers of Hawaii
414 Kuwili St. Ste. 104
Honolulu, HI 96817
Tel: (808) 532-7110
Fax: (808)532-7120
email: [email protected]
Executive Director: Barbara Fischolowitz-Leong
Website: www.atrc.org
ILLINOIS-AT Project
Illinois AT Project
1 W. Old State Capital Plaza, Ste 100
Springfield, IL 62701
Tel: (217) 522-9966
Fax: (217) 522-8067
email: [email protected]
Website: www.iltech.org
IDAHO-PAAT
C0-Ad Inc.
4477 Emerald Street Suite B-100
Boise, ID 83706
Tel: (208) 336-5353
Fax: (208) 336-5396
Website: www.co-adinc.org
email: [email protected]
Corinna Wolfe, AT Advocate
INDIANA-PAAT
Indiana Advocacy Services
4701 N. Keystone Ave. #222
Indianapolis, IN 46205-1554
Tel: (317) 722-5555 ext 228
Fax: (317) 722-5564
Website: www.in.gov/ipas
email: [email protected]
Gary Ricks, Program Coordinator
IDAHO-AT Project
Idaho AT Project
Idaho Center on Developmental Disabilities
University of Idaho
Professional Building
129 West Third St
Moscow, ID 83844-4401
Tel: (208) 885-3559
Fax: (208) 885-3628
email: [email protected]
Website: http://www.educ.uidaho.edu/idatech
INDIANA-AT Project
Assistive Technology Through Action In Indiana Attain, Inc.
5333 Commerce Square Drive, Suite G
Indianapolis, IN 46237
Tel: (317) 543-0236
Fax: (317) 543-0237
email: [email protected]
Website: www.attaininc.org
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IOWA-PAAT
KENTUCKY-AT Project
Iowa Program for Assistive Technology
100 Hawkins Drive Room S295
Iowa City, IA 52245
Tel: (319) 353-8502
Fax: (319) 353-5139
email: [email protected]
Jennifer Britton, Funding Services Coord.
Website: www.uiowa.edu/infotech
Kentucky AT Services Network
Kentucky Dept. for the Blind
KATS Network Coordinating Center
8412 Westport Rd
Louisville, KY 40242
Tel: (800) 327-5287
Fax: (502) 429-7114
email: [email protected]
Website: www.katsnet.org
IOWA-AT Project
LOUISIANA-PAAT
Iowa Program for Assistive Technology
Center for Disabilities and Development
100 Hawkins Drive
Iowa City, IA 52242-1011
Tel: (319) 353-8777
Fax: (319) 384-5139
email: [email protected]
Director: Jane Gay
Website: www.uiowa.edu/infotech
Advocacy Center
1010 Common Street, Ste 2640
New Orleans LA 70112Tel: (504) 522-2337
Fax: (504) 522-5507
Website: www.advocacyla.org
email: [email protected]
Ann Maclaine, Director of Legal Services
KANSAS-PAAT
LOUISIANA-AT Project
Disability Rights Center of Kansas
635 S.W. Harrison Street, Suite 100
Topeka KS 66603-3726
Tel: (785) 273-9661
Fax: (785) 273-9414
Website: www.drckansas.org
email: [email protected]
Mike Donelly, Dir. of Policy & Outreach
email: [email protected]
Rocky Nichols, Executive Director
Louisiana AT Access Network
PO Box 14115
3042 Old Forge Road, Suite D
Baton Rouge, LA 70898-4115
Tel: (800) 270-6185
Fax: (225) 925-9560
email:[email protected]
Website: www.latan.org
MAINE-PAAT
Disability Rights Center
24 Stone Street
P.O.Box 2007
Augusta, ME 04338-2007
Tel: (207) 626-2774
Fax: (207) 621-1419
Website: www.drcme.org
email: [email protected]
Kim Moody, Attorney
KANSAS-AT Project
AT for Kansas
University of Kansas
University Affiliated Program at Parsons AT Center
2601 Gabriel PO Box 738
Parsons, KS 67357
Tel: (800) 526-3648
Fax: (316) 421-0954
email: [email protected]
Website: http://www.atk.ku.edu
MAINE-AT Project
Maine Consumer Information and Technology Exchange
Maine CITE Coordinating Center
University of Maine System Network
46 University Drive
Augusta, ME 04330
Tel: (207) 621-3482
Fax: (207) 621-3193
email: [email protected]
Project Director: Kathleen Powers
Website: www.mainecite.org
KENTUCKY-PAAT
Legal Services &
Resources
Protection & Advocacy Division
100 Fair Oaks Lane 3rd Floor
Frankfort, KY 40601
Tel: (502) 564-2967
Fax: (502) 564-0848
email: [email protected]
Maureen Fitzgerald, Director
email: [email protected]
Melissa L. Bowman, Attorney
Website: www.kypa.net
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MARITIME PROVINCES-PAAT
MICHIGAN-PAAT
Northern Mariana P&A Systems Inc.
PO Box 503529
Saipan, MP 96950
Tel: (011-670) 235-7274
Fax: (011-670) 235-7275
email: [email protected]
Lydia Barcinas, Executive Director
Website: www.nmpasi.com
Michigan P&A Service
4095 Legacy Parkway Ste 500
Lansing MI 48911-4263
Tel: (517) 487-1755
Fax: (517) 487-0827
Website: www.mpas.org
email: [email protected]
Collene Dabish, Dir. of Advocacy Svcs
MARYLAND-PAAT
MICHIGAN-AT Project
Maryland Disability Law Center
1800 N Charles St 4th Floor
Baltimore, MD 21201
Tel: (410) 727-6352
Fax: (410) 727-6389
email: [email protected]
Leslie Seid Margolis, Attorney
email: [email protected]
Elizabeth Fischer, Staff Attorney
[email protected]
Website: www.mdlcbalto.org
Michigan AT Project
740 West Lake Lansing Road, Ste. 200
Lansing, MI 48823
Tel: (800) 760-4600
Fax: (517) 33-2677
Contact: Kathryn Wakeman Wyeth
email: [email protected]
Website: http://www.copower.org/AT/index.htm
MINNESOTA-PAAT
Minnesota Disability Law Center
430 1st Ave. N. #300
Minneapolis, MN 55401-1780
Tel: (612) 332-1441
Fax: (612) 334-5755
Website: www.mdmnlegal.org
email: [email protected]
Pamela Hoopes, Director
email: [email protected]
Jennifer Giesen, Attorney ext 283
MARYLAND-AT Project
Maryland Technology Assistance Program
2301 Argonne Drive
Balitmore, MD 21218-1696
Tel: (800) 832-4827
Fax: (207) 554-9237
email: [email protected]
Executive Director: Michael Dalto
Website: www.mdtap.org
MINNESOTA-AT Project
System of Technology to Achieve Results
Governor’s Advisory Council in Technology for
People with Disablities
50 Sherburne Ave., Room 309
St. Paul, MN 55155
Tel: (651) 201-2640
Fax: (612) 282-6671
email: [email protected]
Executive Director: Chuck Rassbach
Website: www.admin.state.mn.us/assistivetechnology
MASSACHUSETTS-PAAT
Disability Law Center
11 Beacon Street #925
Boston, MA 02108
Tel: (617) 723-8455
Fax: (617) 723-9125
Website: www.dlc-ma.org
email: [email protected]
Stan Eichner, Acting Executive Director
email: [email protected]
Linda Landry, Attorney
MISSlSSIPPI-PAAT
Mississippi P&A System for DD Inc.
5305 Executive Place Suite A
Jackson, MS 39206
Tel: (601) 981-8207
Fax: (601) 981-8313
email: [email protected]
Rebecca Floyd, Attorney
Website: www.mspas.com
MASSACHUSETTS-AT Project
Massachusetts Rehabilitation Commission
27 Wormwood Street, Suite 600
Boston, MA 02110
Tel: (617) 204-3600
Fax: (617) 204-3868
email: [email protected]
Program Director: Karen Langley
Website: http://www.mass.gov/mrc
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MISSlSSIPPI-AT Project (cont)
NEBRASKA-PAAT
Project START
Department of Rehabilitation Services
PO Box 1698
Jackson, MS 39215
Tel: (800) 853-8328
Fax: (601) 364-2349
email: [email protected]
Project Director: Dorothy Young
Website: http://www.msprojectstart.org
Nebraska Advocacy Services
134 south 13th Street, Ste 600
Lincoln NE 68508
Tel: (402) 474-3183
Fax: (402) 474-3274
email: [email protected]
Diane DeLair, Attorney
Website: www.nebraskaadvocacyservices.org
NEBRASKA-AT Project
MISSOURI-PAAT
Nebraska AT Partnership
5143 South 48th St. Ste. C
Lincoln, NE 68516-2204
Tel: (888) 806-6287
Fax: (402) 471-6052
email: [email protected]
Project Director: Mark Schultz
Website: http://www.atp.ne.gov/
Missouri P & A Services
925 South Country Club Drive Unit B-1
Jefferson City, MO 65109
Tel: (573) 659-0678
Fax: (573) 659-0677
Shawn DeLoyola, Director
Cecilia Callahan, Director of Advocacy
Website: www.moadvocacy.org
NEVADA-PAAT
MISSOURI-AT Project
Disability Advocacy & Law Center
6039 Eldora, Suite C-3 Box 3
Las Vegas, NV 89146-5611
Tel: (702) 257-8150
Fax: (702) 257-8170
Website: www.ndalc.org
email: [email protected]
William Heaivilin, Supervising Attorney
Missouri AT Project
Missouri Dept. of Labor and Industrial Relations
4731 South Cochise Ste. 114
Independence, MO 64055-6975
Tel: (800) 647-8558
Fax: (816) 373-9314
email: [email protected]
Website: http://www.at.mo.gov
NEVADA-AT Project
MONTANA-PAAT
Nevada AT Collaborative
Department of Human Resources
Office of Disability Service
3656 Research Way, Suite 32
Carson City, NV 89701
Tel: (775) 687-4452
Fax: (775) 687-3292
email: [email protected]
Project Administrator: Kelleen Preston
Website: http://hr.state.nv.us/directors/disabilitysvcs/dhr_ods.htm
MAP- DLC
400 North Park 2nd Floor PO Box 1681
Helena MT 59624
Tel: (406) 449-2344
Fax: (406) 449-2418
Website: www.mtadv.org
email: [email protected]
Phillip Hohenlohe, Attorney
MONTANA-AT Project
NEW HAMPSHIRE-PAAT
Disabilities Rights Center
P.O. Box 3660
18 Low Ave
Concord, NH 03302-3660
Tel: (603) 228-0432
Fax: (603) 225-2077
Website: www.drcnh.org
email: [email protected]
Richard Cohen, Executive Director
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Legal Services &
Resources
MonTECH
Rural Institute on Disabilities
The University of Montana
634 Eddy Avenue
Missoula, MT 59812
Tel: (406) 243-5676
Fax: (406) 243-4730
email: [email protected]
Project Director: Kathy Laurin
Website: http://montech.ruralinstitute.umt.edu
NEW HAMPSHIRE-AT Project
NEW YORK-PAAT
University of New Hampshire
Institute on Disability/UCE
10 West Edge Drive, Suite 101
Durham, NH 038241
Tel: (800) 238-2048
Fax: (603) 228-3270
email: [email protected]
Website: http://www.iod.unh.edu/projects/technology_policy.html
Neighborhood Legal Services
295 Main St. Room 495
Buffalo, NY 14203
Tel: (716) 847-0650
Fax: (716) 847-0227
Website: www.nls.org
email:[email protected]
James Sheldon, Supervising Attorney
email: [email protected]
Ron Hager, Attorney
email: [email protected]
Marge Gustas, Paralegal
email: [email protected]
Diana Straube, Attorney
NEW JERSEY-PAAT
New Jersey P&A
210 So. Broad St. 3rd Floor
Trenton, NJ 08608
Tel: (609) 292-9742
Fax: (609) 777-0187
Website: www.njpanda.org
email: [email protected]
Jamie Prioli, AT Practitioner
NEW YORK-AT Project
NEW JERSEY-AT Project
Assistive Technology Advocacy Center (ATAC) of NJ P&A
210 South Broad St 3rd Floor
Trenton, NJ 08608
Tel: (609) 292-9742
Fax: (505) 777-0187
email: [email protected]
Project Director: Curtis Edmonds
Website: www.njpanda.org/tarp/index.html
NEW MEXICO-PAAT
Protection & Advocacy System Inc
1720 Louisiana Blvd. NE #204
Albuquerque, NM 87110
Tel: (505) 256-3100
Fax: (505) 256-3184
Website: www.nmpanda.org
email: [email protected]
Jim Jackson, Director
email: [email protected]
Ann Chavez, Advocate
NEW MEXICO-AT Project
New Mexico Technology-Related Assistance Program
435 Saint Michaels Dr. Bld. D
Santa Fa, NM 87505
Tel: (800) 866-2253
Fax: (505) 954-8608
email: [email protected]
Project Director: Andrew J. Winnegar
Website: www.nmtap.com
NYS Commission on Quality Care and Advocacy for Persons
with Disabilities
401 State Street
Schenectady, NY 12305
Tel: (518) 388-2888
Fax: (518) 388-2890
email: [email protected]
Website: http://www.cqcapd.state.ny.us
NORTH CAROLINA-PAAT
Gvnr's Advocacy Ccl for Persons w/Disabilities
2113 Cameron St. #218
Raleigh, NC 27605-1344
Tel: (919) 733-9250
Fax: (919) 733-9173
Website: www.gacpd.com
email: [email protected]
Iris Green, AT Lawyer
NORTH CAROLINA-AT Project
North Carolina AT Project
North Carolina Dept. of Human Resources
Division of Vocational Rehabilitation Services
1110 Navaho Dr. Ste. 101
Raleigh, NC 27609-7322
Tel: (919) 850-2787
Fax: (919) 850-2792
email: [email protected]
Acting Project Director: Annette Laube
Website: http://www.ncatp.org
NORTH DAKOTA-PAAT
North Dakota Protection and Advocacy
400 E Broadway ste 616
Bismarck, ND 58501
Tel: (701) 328-2950
Fax: (701) 328-3934
Website: www.ndpanda.org
email: [email protected]
Teresa Larsen, Executive Director
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NORTH DAKOTA-PAAT (cont)
OKLAHOMA-PAAT
North Dakota Protection and Advocacy
1351 Page Dr Ste 303
Fargo ND 58103-3551
Tel: (701) 239-7222
Fax: (701) 239-7224
Website: www.ndpanda.org
email: [email protected]
Craig Sinclair, AT Attorney
Oklahoma Disability Law Center
2915 Classen Blvd #300
Oklahoma City, OK 73106
Tel: (v/tdd) (405) 525-7755
Fax: (405) 525-7759
Website: www.oklahomadisabilitylaw.org
email: [email protected]
Kayla Bower, Executive Director
NORTH DAKOTA-AT Project
OKLAHOMA-AT Project
North Dakota Interagency Program For Assistive Technology
3509 Interstate Blvd.
Fargo, ND 58103
Project Director: Judie Lee
Tel: (701) 365-4729
Fax: (701) 239-7229
Email: [email protected]
Web: http://www.ndipat.org
Oklahoma ABLE Tech
Oklahoma State University
1514 West Hall of Fame
Stillwater, OK 74078
Tel: (405) 744-9864
Fax: (405) 744-2487
email: [email protected]
Project Manager: Linda Jaco
Website: http://okabletech.okstate.edu
Northern Mariana Islands-AT Project
CNMI System of Technology-Related Assistance for
Individuals with Disabilities
CNMI Governor’s Developmental
Disabilities Council
Commonwealth of Northern Mariana Islands
PO Box 502565
Saipan, MP 96950-2565
Tel: (011-670) 664-7000
Fax: (011-670) 664-7030
email: [email protected]
Project Director: Tony Chong
Website: http://www.cnmiddcouncil.org
OHIO-PAAT
Ohio Legal Rights Service
8 East Long St. 5th Floor
Columbus, OH 43215
Tel: (614) 466-7264
Fax: (614) 644-1888
TDD: (614) 728-2553
Website: http://olrs.ohio.gov
email: [email protected]
Carolyn Knight, Executive Director
email: [email protected]
Tim Tobin, Disability Policy Director
OHIO-AT Project
Oregon Advocacy Center
620 SW Fifth Ave. 5th Floor
Portland, OR 97204
Tel: (503) 243-2081
Fax: (503) 243-1738
Website: www.oradvocacy.org
email: [email protected]
Jan Friedman, Attorney
email: [email protected]
Molly Sullivan, Advocate
Oregon Advocacy Center
75 North 1st Street
Central Point OR 97502
Phone: (541) 664-3024
Fax: (541) 664-3384
TTY: (800) 556-5351
Website: www.oradvocacy.org
email: [email protected]
Julie Anderson, Attorney
OREGON-AT Project
Technology Access for Life Needs
Oregon Disabilities Commission
3070 Lancaster Dr. NE
Salem, OR 97305
Tel: (503) 361-1201
Fax: (503) 370-4530
email: [email protected]
Executive Director: Laurie Brooks
Website: http://www.accesstechnologiesinc.org
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Legal Services &
Resources
445 East Dublin Granville Rd., Building L
Worthington, OH 430851
Tel: (614) 292-3162
Fax: (614) 292-5866
email: [email protected]
Website: www.atohio.org
OREGON-PAAT
PENNSYLVANIA-PAAT
RHODE ISLAND-AT Project
Pennsylvania P&A Inc.
1414 N Cameron St STE C
Harrisburg, PA 17103
Tel: (717) 236-8110
Fax: (717) 236-0192
Website: www.ppainc.org
email: [email protected]
Pam Auer
email: [email protected]
Judy Banks
Rhode Island AT Access Partnership
Rhode Island Dept. of Human Services
Office of Rehabilitation Services
40 Fountain St.
Providence, RI 02903-1898
Tel: (401) 421-7016
Fax: (401) 421-9259
email: [email protected]
Project Director: Kathleen Burrell
Website: www.atap.state.ri.us
PENNSYLVANIA-AT Project
SOUTH CAROLINA-PAAT
Pennsylvania’s Initiative on AT
Institute on Disabilities/UCEDD University
Services Building
1601 North Broad Street
Philadelphia, PA 19122
Tel: (215) 204-1356
Fax: (215) 204-9371
email: [email protected]
Program Director: Amy S. Goldman
Website: http://disabilities.temple.edu
S. Carolina P&A for People with Disabilities
3710 Landmark Drive, Ste 208
Columbia SC 29204
Tel: (803) 782-0639
Fax: (803) 790-1946
Website: www.protectionandadvocacy-sc.org
email: [email protected]
David Zoellner, Attorney
PUERTO RICO-PAAT
Office of Ombudsman for Persons with Disabilities
P.O. Box 41309
San Juan, PR 00904-1309
Tel: (800) 981-4125
Fax: (787) 721-2455
Website: www.oppi.gobierno.pr
email: [email protected]
Enrique Rodríguez, Deputy Ombudsman
email: [email protected]
José R. Ocasio, Ombudsman
PUERTO RICO-AT Project
University of Puerto Rico
Central Administration/FILIUS Instituto
Assistive Technology Institute
Jardin Botanico Sur
1187 Calle Flamboyan
San Juan, PR 00926-1117
Tel: (787) 754-8034
Fax: (787) 759-3645
email: [email protected]
Program Director: Maria I. Miranda
Website: http://www.pratp.upr.edu
RHODE ISLAND-PAAT
Rhode Island Disability Law Center
349 Eddy Street
Providence, RI 02903
Tel: (401) 831-3150
Fax: (401) 274-5568
Website: www.ridlc.org
email: [email protected]
Anne Mulready, Project Supr./Staff Attorney
SOUTH CAROLINA-AT Project
South Carolina AT Program
USC School of Medicine
Center for Disability Resources
Columbia, SC 29208
Tel: (803) 935-5263
Fax: (803) 935-5342
Project Director: Evelyn Evans
email: [email protected]
Website: www.sc.edu/scatp
SOUTH DAKOTA-PAAT
South Dakota Advocacy Services
221 S. Central
Pierre, SD 57501
Tel: (605) 224-8294
Fax: (605) 224-5125
Website: www.sdadvocacy.com
email: [email protected]
Chris Houlette, Staff Attorney
email: [email protected]
Robert Kean, Executive Director
SOUTH DAKOTA-At Project
DakotaLink
1161 Deadwood Ave. Suite #5
Rapid City, SD 57702
Tel: (605) 394-6742
Fax: (605) 394-6744
Email: [email protected]
Web: http://DakotaLInk.tie.net
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TENNESSEE-PAAT
U.S. Virgin Islands-AT Project
Tennessee Protection and Advocacy
2146 21st Ave. S.
PO Box 121257
Nashville, TN 37212
Tel: (615) 298-1080
Fax: (615) 298-2046
Website: www.dlactn.org
email: [email protected]
Shirley Shea, Executive Director
email: [email protected]
Cindy Gardner, AT Attorney
email: [email protected]
Gary Housepain, Managing Attorney
US Virgin Islands Technology-Related Assistance for
Individuals with Disabilities
University of the Virgin Islands/University Affiliated Program
#2 John Brewer Bay
St. Thomas, VI 00801-0990
Tel: (340) 693-1323
Fax: (340) 693-1325
email: [email protected]
Executive Director: Yegin Habtes
Website: http://www.uvi.edu/pub-relations/VIUCEDD/index.htm
TENNESSEE-AT Project
Tennessee Technology Access Project
Citizens Plaza, 14th Floor
400 Deaderick Street
Nashville, TN 37248-6000
Tel: (615) 313-5183
Fax: (615) 532-4685
email: [email protected]
Program Director: Kevin R. Wright
Website: www.state.tn.us/humanserv/rehab/ttap.htm
TEXAS-PAAT
Advocacy Inc.
7800 Shoal Creek Blvd #171-E
Austin, TX 78757
Tel: (512) 454-4816
Fax: (512) 454-3999
Website: www.advocacyinc.org
email: [email protected]
Garth Corbett, Managing Director-Legal Unit
email: [email protected]
Steve Elliot, Senior Attorney
TEXAS-AT Project
Texas Center for Disability Studies
University of Texas at Austin
4030-2 West Braker Lane, Suite 220
Austin, TX 78759
Tel: (512) 232-0762
Fax: (512) 232-0761
email: [email protected]
Director: Penny Seay, Ph.D.
Website: http://techaccess.edb.utexas.edu
UTAH-PAAT
Disability Law Center
205 North 400 West
Salt Lake City UT 84103
Tel: (801) 363-1347
Fax: (801) 363-1437
Web page: www.disabilitylawcenter.org
e-mail: [email protected]
Kerry Chlarson, Legal Director
email: [email protected]
Matt Knotts, PAAT Coordinator
UTAH-AT Project
Utah AT Program
Utah State University
Center for Persons with Disabilities
6588 Old Main Hill
Logan, UT 84322-6588
Tel: (435) 797-7089
Fax: (435) 797-2355
email: [email protected]
Website: www.uatpat.org
VERMONT-PAAT
Disability Law Project (main)
264 Winooski Ave
Burlington VT 05402
Tel: (802) 863-5620
Fax: (802) 863-7152
www.vtlegalaid.org
Jane Callahan, Paralegal
[email protected]
Page 90
Reprinted with permission - Altimate Medical, Inc. - makers of EasyStand products ©2007
Legal Services &
Resources
Disability Law Project
PO Box 1367
Burlington, VT 05701
Tel: (800) 747-5022
Fax: (802) 863-7152
Website: www.vtlegalaid.org
email: [email protected]
Barbara Prine, Attorney
email: [email protected]
Bessie Weiss, Attorney
Joe Reinert, Attorney
email: [email protected]
VERMONT-PAAT (cont)
Disability Law Project
57 North Main Street
Rutland, VT 05701
Tel: (802) 263-2881
Fax: (802) 863-7152
email: [email protected]
Nancy Breiden, Director
email: [email protected]
Laurie Beyranevand, Attorney
VIRGIN ISLANDS
Virgin Islands Advocacy Agency
63 Estate Cane Carlton Fredericksted
FSt Croix, VI 00840
Tel: (809) 772-1200
Fax: (809) 772-0609
Website: www.drcvi.org
email: [email protected]
Zulma Turner, Senior Advocate
VIRGINIA-PAAT
Senior Citizens Law Project
56 Main Street Suite 301
Springfield, VT 05156
Tel: 802-885-5181
Fax: 802-885-5754
Website: www.vtlegalaid.org
email: [email protected]
Marilyn Matusky, Attorney
email: [email protected]
Brigid Lynch, Attorney
Disability Law Project
18 Main Street
St. Johnsburg, VT 05819
Tel: 802-748-8721
Fax: 802-748-4610
Website: www.vtlegalaid.org
Disability Law Project
PO Box 606
Montpelier VT 05601
Tel: (802) 223-6377
Fax: (802) 223-7281
www.vtlegalaid.org
Sherrie Brunelle, Paralegal
email:[email protected]
Lila Richardson, Attorney
email: [email protected]
Disability Law Project
177 Western Ave Ste 1
St Johnsbury VT 05819
Phone: (802) 748-8721
Fax: (802) 748-4610
www.vtlegalaid.org
Laura Damm, Attorney
email: [email protected]
Virginia Office for P&A
1910 Byrd Ave STE 5
Richmond VA 23230
Tel: (804) 225-2042
Fax: (804) 662-7431
www.vopa.state.va.us
Julie Kegley, Attorney
email: [email protected]
VIRGINIA-AT Project
Virginia AT System
Dept. of Rehabilitative Services
8004 Franklin Farms Drive
Richmond, VA 23288-0300
Tel: (804) 662-9990
Fax: (804) 662-9478
email: [email protected]
Director: Ken Knorr
Website: www.vats.org
WASHINGTON-PAAT
Washington P&A Systems
315 5th Ace. S. Suite 850
Seattle, WA 98104
Tel: (206) 324-1521
Fax: (206) 957-0729
Website: www.wpas-rights.org
email: [email protected]
Michael J. Smith, Attorney
email: [email protected]
Abbey Ceja, Administrative Assistant
WASHINGTON-AT Project
VERMONT-AT Project
Vermont AT Project
103 South Main St.
Weeks Building, First Floor
Waterbury, VT 05671-2305
Tel: (802) 241-2620
Fax: (802) 241-2174
email: [email protected]
Project Director: Julie Tucker
Website: http://www.dail.state.vt.us/atp
Washington AT Alliance
University of Washington
Center for Technology and Disability Studies
CHDD South Building, Room 104
PO Box 357920
Seattle, WA 98195-7920
Tel: (206) 616-1396
Fax: (206) 543-4779
email: [email protected]
Website: http://wata.org
Page 91
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WEST VIRGINIA-PAAT
WYOMING-AT Project
West Virginia Advocates
1207 Quarrier Street 4th Floor
Charleston, WV 25301
Tel: (304) 346-0847
Fax: (304) 346-0867
email: [email protected]
Susan Given, Program Director
email: [email protected]
Clarice Hausch, Executive Director
email: [email protected]
Todd Rundle, Advocate
WIND Assistive Technology Resources, Wyoming Institute
for Disabilities, University of Wyoming
Box 4298
Laramie, WY 82072-4298
Tel: (307) 766-2764
Fax: (307) 766-2763
email: [email protected]
WATR Program Director: Sandra Root-Elledge
Website: http://wind.uwyo.edu/watr
WEST VIRGINIA-AT Project
West Virginia AT System
WVUCED
Robert C. Byrd Health Sciences Center
955 Hartman Run Road
Morgantown, WV 26505
Tel: (304) 293-4692
Fax: (304) 293-7294
email: [email protected]
WISCONSIN-PAAT
Wisconsin Coalition for Advocacy
6737 West Washington St, #3230
Milwaukee WI 53214
Tel: (414) 773-4646
Fax: (414) 773-4647
Website: www.w-c-a.org
e-mail: [email protected]
Palmer Bell, Director of PAAT
email: [email protected]
Monica Murphy, AT Attorney
WISCONSIN-AT Project
WisTech
Wisconsin AT Program
Division of Supportive Living
PO Box 7851
1 W. Wilson Street, RM 450
Madison, WI 53707
Tel: (608) 267-9880
Fax: (608) 268-3203
Program Director: Holly Laux O'Higgin
email: [email protected]
Website: http://dhfs.wisconsin.gov/disabilities/wistech/index.htm
Legal Services &
Resources
WYOMING-PAAT
Protection & Advocacy System Inc
320 West 25th Street 2nd Floor
Cheyenne, WY 82001
Tel: (307) 632-3496
Fax: (307) 638-0815
Website: www.wypanda.vcn.com
email: [email protected]
Buck Gwyn, Senior Staff Attorney
Page 92
Reprinted with permission - Altimate Medical, Inc. - makers of EasyStand products ©2007
Helpful Websites
AAPD
American Association of People with Disabilities
www.aapd-dc.org
ABLEDATA
Information on Assistive Technology and Links to State Assistive Technology Projects
www.abledata.com
ALTIMATE MEDICAL, INC.
Makers of EasyStand Standing Products
www.easystand.com
AOTA
American Occupational Therapy Association
www.aota.org
APTA
American Physical Therapy Association
www.apta.org
CENTERS FOR MEDICARE & MEDICAID SERVICES
www.cms.hhs.gov
FAMILIES USA
www.familiesusa.org
ITEM COALITION
Independence Through Enhancement of Medicare and Medicaid
www.itemcoalition.org
NATIONAL ASSISTIVE TECHNOLOGY ADVOCACY PROJECT
www.nls.org/natmain.htm
NCART
National Coalition for Assistive and Rehab Technology
www.ncart.us
NRRTS
National Registry of Rehabilitation Technology Suppliers
www.nrrts.org
RESNA
The Rehabilitation Engineering and Assistive Technology Society of North America
www.resna.org
Page 93
Reprinted with permission - Altimate Medical, Inc. - makers of EasyStand products ©2007
Quick Fit Guide Select the Stander that Provides the Perfect Fit
um
xim
Ma
t
igh
We
er
Us
it
Lim
ack
hB
wit
ge
an
eR
lat
tP
o
Fo
ge
an
tR
igh
He
e
ng
Ra
pth
De
at
Se
to
at
Se
ate
xim
pro
Ap
Magician•ei
28”-40”
71-102 cm
3”-15”
8-38 cm
6.5”-11”
16-28 cm
45 lbs.
20 kg
Magician Comfy
3’-4’6”
91-137 cm
9.5”-16”
24-41 cm
10.5”-15.5”
27-39 cm
100 lbs.
45 kg
Magician Original
3’-4’6”
91-137 cm
9”-15”
23-38 cm
10.5”-15.5”
27-39 cm
100 lbs.
45 kg
Evolv Youth Basic
4’0”-5’6”
122-168 cm
14”-21”
36-53 cm
14”-19”
36-48 cm
200 lbs.
90 kg
Evolv Adult Basic
5’0”-6’2”
152-188 cm
14”-21”
36-53 cm
16”-21”
41-53 cm
280 lbs.
127 kg
Evolv Youth Glider
4’0”-5’6”
122-168 cm
15”-18”
38-46 cm
14”-19”
36-48 cm
200 lbs.
90 kg
Evolv Adult Glider
5’0”-6’2”
152-188 cm
15”-18”
38-46 cm
16”-21”
41-53 cm
280 lbs.
127 kg
Evolv Youth Mobile
4’0”-5’6”
122-168 cm
14”-21”
36-53 cm
14”-19”
36-48 cm
200 lbs.
90 kg
Evolv Adult Mobile
5’0”-6’2”
152-188 cm
14”-21”
36-53 cm
16”-21”
41-53 cm
280 lbs.
127 kg
Evolv Youth Shadow Tray
4’0”-5’6”
122-168 cm
14”-21”
36-53 cm
14”-19”
36-48 cm
200 lbs.
90 kg
Evolv Adult Shadow Tray
5’0”-6’2”
152-188 cm
14”-21”
36-53 cm
16”-21”
41-53 cm
280 lbs.
127 kg
StrapStand
5’0”-6’5”
152-195 cm
N/A
N/A
350 lbs.
159 kg
5000 Youth
4’0”-5’6”
122-168 cm
11”-19”
28-48 cm
14”-18”
36-46 cm
180 lbs.
82 kg
5000
5’0”-6’5”
152-195 cm
11”-19”
28-48 cm
16”-22”
41-56 cm
280 lbs.
127 kg
10”-20”
25-51 cm
18”-24”
41-61 cm
350 lbs.
159 kg
5000 XL
Page 94
5’5”-6’10”
165- 208 cm
Coding
Standing Technology
Altimate Medical, Inc. applied for code verification to the HCPCS National Panel in April of 2003. November
of 2003 AMI received documents announcing that code modifications had been made to the HCPCS level II
set of code categories, highlighting E0637 as the new code for Sit to Stand Systems effective January 1, 2004.
Altimate Medical continues to work with NCART to secure appropriate HCPCS codes for standing devices. We
understand the importance of weight bearing / standing to our consumers.
HCPCS Code: E0637
Short Description: Sit – Stand w/seatlift
Long Description: Combination sit to stand system, any size, with seat lift feature, with or without wheels.
Medical Necessity:
This device is used by the child/adult who requires anterior and posterior body support and alignment
during incremental weight bearing from sitting to upright standing or any area in between, whose
diagnoses, prognosis or symptomatology necessitates one or more of the following:
•
•
•
•
•
•
•
•
Facilitating a symmetrical posture.
Developing and improving head, neck and upper body muscle control.
Inhibiting abnormal muscle tone and reflexes.
Preventing loss of range of motion.
Alleviating pain caused by inappropriate and or prolonged position.
Improving systemic functions; i.e. bladder, respiratory, digestive and circulatory.
Preventing loss of bone density.
Developing standing tolerance and endurance.
Suggested Documentation:
A Letter of Medical Justification including but not limited to:
• Complete client information.
• Diagnosis and brief medical history.
• Description of functional goals, current program, ADL’s and relevant impairments.
• Client’s history of standing and compliance.
• Description of devices considered, including least & most costly alternatives and a detailed
standing device trail description.
• Outcomes expected and prescribed standing program.
• Physician, therapist, and supplier signature.
Payer criteria and reimbursement rates for standing technology vary among funding sources. Be sure to
understand your payer’s documentation needs.
Altimate Medical, Inc. does not guarantee reimbursement of product with this code.
Verify HCPCS code with payer source.
Page 95
Altimate Medical, Inc. - makers of EasyStand products ©2007
seventh edition
Supporting
Articles
™
•
Research
References Summary
seventh edition
Standing technology should only be used under the guidance of a physician with recommendations for standing program protocol and any
medical precautions. Standing programs should be monitored by the attending therapist. AMI maintains a policy of continual product
improvement and reserves the right to change features, specifications, and prices without prior notification. Check with AMI for latest info.
FORM LMN 0907 Copyright © 2007 Altimate Medical, Inc. All rights reserved. Printed in the U.S.A.
Compliments of Altimate Medical, Inc.
The makers of EasyStand products
Legal Services &
Resources
™
Altimate Medical
This book is also available in
downloadable format at
www.easystand.com
Funding Hotline: 877.844.1172
Phone: 800.342.8968 or 507.697.6393
Fax: 877.342.8968 or 507.697.6900
email: [email protected]
www.easystand.com
Research Studies
•
P.O. Box 180
262 West 1st St
Morton, MN 56270, USA
Letter of
Medical Necessity
Funding Guide for Standing Technology
Funding Guide for
Standing Technology
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