The Hidden Benefits of Standing: Why Upright Time Matters After SCI
A spinal cord injury can rob individuals of the ability to stand unaided. When walking isn't achievable or practical, standing itself - simply being upright and weight-bearing - delivers a range of benefits that are often underestimated.
This article explores what regular standing can do for your health after SCI. Some of these benefits are well-established in research; others are consistently reported by people who stand regularly. All of them are worth understanding.
In the past, spinal injury units would often provide basic standing frames for clients on discharge, but this generally doesn't happen any more. Perhaps the most common standing frame I used to see was a wooden frame that might have been used enthusiastically at the beginning but frequently became an unwanted close horse sitting in the living room. Just standing,without the ability to do anything more useful, Is not an attractive prospect for most people. Despite being encouraged to stand for their health, many people found just doing this just boring, and motivation was lacking.
Standing can facilitate social interaction. TekRMD allows you to move as well as stand tall.
Today, there are improved standing devices that perhaps allow exercise to take place while standing. There are so-called standing wheelchairs and a device that we are passionate about, the TekRMD from Matia Robotics that combines upright standing with good posture with an ability to move around in your environment. Before we get into the product, let's consider the case for weight bearing.
The Case for Weight-Bearing
Humans evolved to spend significant time upright. Our bodies expect the mechanical loading that comes from standing and walking. When that loading stops - as it does after paralysis - systems that depend on it begin to change. This isn't about what's "natural" in some romantic sense. It's about physiology. Weight-bearing through the skeleton triggers biological processes. Remove the loading, and those processes slow or stop. The consequences accumulate over time. The body works basically on a use it or lose it principle. Regular standing helps maintain the body systems that otherwise deteriorate and that matters for long-term health.
The UK Clinical Guideline for Standing in Adults Following Spinal Cord Injury recommends assessing for standing "as soon as physiologically stable" with Grade A evidence, the highest level of clinical recommendation.
Joint Contracture Prevention and Range of Motion
This is one of the most strongly evidenced benefits of standing after SCI. Contractures - permanent shortening of muscles and joints - are common after SCI and significantly impact positioning, skin integrity, and care needs. The constant forces of immobility work against joint mobility 24 hours a day; brief, intermittent stretching is often insufficient to counter them.
Standing helps because gravitational positioning extends the hip and knee joints while applying body weight vertically through both feet. This stretches surrounding muscles more effectively than supine stretching alone. A systematic review by Glickman and colleagues (2010) found moderate to high quality evidence supporting the positive impact of standing on range of motion. It stands to reason that a standing regime should be introduced as soon as practical in spinal cord injury rehabilitation, as this will help to prevent the possibility of contractures developing.
Research by Gibson et al. (2009) demonstrated improved joint range of motion after standing frame use compared to no standing. Walter et al. (1999) found increased joint range of motion with extended standing periods. Adults using tilt tables with dorsiflexion wedges showed decreased plantar flexor spasticity and improved ankle mobility.
Standing can be a practical way to eliminate plantar flexion contractures when used consistently. Early intervention is significantly more effective than attempting to reverse established contractures - prevention is far easier than treatment.
Spasticity Management
Standing addresses spasticity through two mechanisms, and this benefit is well-documented in the literature.
Providing a prolonged stretch Upright weight-bearing stretches the hip flexors, knee flexors, and ankle plantarflexors in a sustained way. Prolonged stretch reduces muscle tone and can decrease spasticity.
Weight-bearing inhibition. Research by Odeen and Knutsson demonstrated spasticity reduction in SCI subjects following a single 30-minute tilt table session, measured by reduced resistance during passive movement. There's evidence that loading through the skeleton has direct inhibitory effects on spinal reflexes.
Glickman and Geigle's systematic review (2010) found that standing decreased extensor spasms more effectively than body weight-supported treadmill training. In the survey by Dunn, Walter and colleagues (2001), reduced muscle spasms was the most prevalent benefit reported. Bohannon's research confirmed immediate spasticity reduction on the Modified Ashworth Scale.
There is an important caveat, however. The RESNA systematic review found that while subjective improvements are consistently reported, objective measurements on standardised scales sometimes show statistically insignificant changes. Benefits are also transient, lasting approximately 1.4 days on average, which is why regular, consistent standing is essential. Despite the research, many people report reduced spasticity for hours after a standing session. For those whose spasticity is problematic, regular standing may be a useful addition to their management, potentially reducing medication requirements. In our experience, when standing does not reduce spasticity, electrical stimulation and other techniques might be usefully deployed.
Psychological and Social Benefits
These benefits are consistently and strongly reported in research surveys, even if harder to measure objectively. Clients often talk to us about how they just love to relate to people eye to eye rather than always looking up at them from a wheelchair.
The evidence is compelling. In the study by Dunn, Eng and Walter (2001) surveying 126 SCI patients, 87% reported improved wellbeing as the most prevalent psychological benefit. Walter et al. (1999) found that patients standing 30 minutes or more daily reported significantly improved overall quality of life. Participants in these studies described benefits including: "It feels great to look others in the eyes" and "It allows me to see things from a different view." More than one-third of respondents reported improved self-care and independence in activities of daily living.
Being upright changes your visual perspective, your interaction with others, and perhaps your sense of self. The psychological value of eye-level conversation shouldn't be dismissed. Devices that enable standing mobility - like the Tek RMD - allow reaching high shelves, accessing environments designed for standing people, and engaging socially in ways that sitting cannot replicate. It should be obvious that standing by itself doesn't bring psychological benefits unless it facilitates social interaction. So often I've seen a standing frame positioned so that the user, when upright, is facing a blank wall. Not much social interaction going on there.
Actively participating in a standing programme is something you do for your health. This sense of agency - taking action rather than passively accepting decline - might have some psychological value in itself but I suspect it's modest compared to what is gained through social interaction.
Research suggests 60 minutes daily may be optimal for mental health benefits, compared to 30 minutes for physical outcomes.
Circulation and Cardiovascular Health
Standing changes circulatory dynamics in ways that matter, with consistent patient-reported benefits. When you stand, gravity pulls blood toward your legs. The cardiovascular system must respond - adjusting heart rate and blood vessel tone - to maintain blood pressure and brain perfusion. This orthostatic stress is a form of cardiovascular conditioning.
In the Dunn et al. study, more than 50% of respondents reported circulation improvements. The most prevalent specific benefit was reduced leg and foot swelling. Research by Ragnarsson and colleagues found that glomerular filtration rate approached normal values in quadriplegic patients when upright, but not when supine.
Orthostatic hypotension (blood pressure dropping when upright) is common after injuries that are at a high level (above T6). Multiple studies show that repeated standing episodes reduce orthostatic hypotension in acute SCI - the cardiovascular system can be trained to respond better to positional changes over time. Better leg circulation may help with wound healing, reduce swelling, and decrease risk of blood clots. A protocol of 30 minutes daily, distributed across multiple shorter sessions, may optimise these benefits.
Bowel and Bladder Function
The effects on elimination are less discussed but very important for quality of life, with supportive survey evidence.
Gravity assists bowel transit. In Walter et al.'s research, patients standing 30 minutes or more daily reported improved bowel regularity. Dunn and colleagues found 23% of respondents reported improved bowel regularity from their standing programme. The same research found 21% reported improved bladder emptying with reduced bladder infections. Upright positioning may support more complete bladder drainage, reducing residual urine.
These effects are modest and variable. Standing isn't a cure for neurogenic bowel or bladder for example. But as part of a comprehensive management strategy, it may contribute to better function. The research is based primarily on patient-reported outcomes rather than controlled trials, so individual results will vary.
Pain Management
Survey evidence suggests standing can help with chronic pain after SCI. In the study by Dunn, Eng and Walter, 30% of 126 respondents reported pain reduction from prolonged standing. These participants stood an average of 40 minutes per session, 3-4 times weekly. A 20-year case study documented decreased chronic pain severity alongside reduced spasticity from a nightly standing programme.
Standing may counter effects of immobility and provide benefits similar to stretching, postural retraining, and activity pacing. It may decrease overuse syndromes and muscle tension that develop from prolonged sitting.
Put this in context. Up to 80% of SCI patients experience some form of long-term pain. Standing is just one component of comprehensive pain management, not a standalone solution, but potentially a useful addition.
Skin Health and Pressure Management
Standing can constitute another form of pressure relief for vulnerable ischial tuberosities. Survey data and clinical experience support the benefit. The issue with sitting isn't pressure per se; it's prolonged pressure on the same areas (ischium, sacrum). Standing shifts weight-bearing to different tissues (feet, legs) and unloads the areas most vulnerable to pressure injury from sitting.
Walter et al. found that patients standing 30 minutes or more daily reported significantly fewer pressure ulcers. There was a significant correlation between time spent standing and reduction in pressure injuries. Research shows 62.4% of surveyed veterans experienced pressure ulcers after SCI. Standard pressure relief recommendations suggest repositioning every 15-30 minutes while seated - but studies show most spontaneous pressure-relieving movements achieve less than 25% reduction in interface pressure. Standing offers complete offloading of seated pressure points. Including standing in your daily routine effectively provides pressure relief time for sitting surfaces. An hour of standing is an hour during which your buttocks aren't bearing load.
Bone Density:
This is often cited as a benefit of standing but the evidence is less clear than commonly assumed. Of course, the problem is real enough. After paralysis, bone density in the legs decreases rapidly. During the first year post-injury, individuals lose approximately 3-4% of bone mineral density per month. Overall, there's a 30-40% decrease in bone density in the legs after SCI. By two years post-injury, bone density may be comparable to a 70-year-old female. About 80% of individuals with chronic SCI have either osteopenia or osteoporosis.
Mechanical loading through bone should stimulate osteoblast activity (the cells that build bone) and reduce osteoclast activity (the cells that break bone down). Regular weight-bearing through standing should help maintain bone density.
However, the evidence is inconclusive. A cross-sectional study of 71 patients found those standing more than one hour daily showed a slight tendency toward higher bone mineral density scores, but the difference was not statistically significant. The SCIRE (Spinal Cord Injury Research Evidence) project classifies the evidence as "inconclusive" for passive standing as a treatment for low bone mass. They note there is currently "no treatment that prevents osteoporosis in non-ambulatory people with SCI." There is some evidence that FES cycling can be beneficial to preserve bone density, but again this demands muscle contractions to be strong enough and the frequency of application to be enough to stimulate the required effect. In my view, the best that can be expected from FES cycling is to preserve bone density, but it will not tend to reverse what is lost.
One study found significantly higher bone density in long leg brace users compared to standing frame users, suggesting the intensity of mechanical loading may matter more than standing alone. Early intervention (within 4 months post-injury) with high frequency may be more effective than later intervention.
I wouldn't recommend standing primarily for bone density preservation, the evidence doesn't strongly support it. But standing delivers enough other proven benefits that bone effects, if they exist, are a bonus rather than the main justification.
Respiratory Function: Limited Evidence
For completeness, I should mention that respiratory benefits are sometimes claimed for standing, but the evidence is limited. Interestingly, for high cervical injuries, patients often report less breathlessness when supine compared to sitting, because the supine position forces the diaphragm to a higher resting level. Research shows a 15-degree head-down tilt from supine increases vital capacity by an additional 6% in tetraplegia.
Standing may benefit those with lower-level injuries by improving lung expansion, but there's limited direct evidence. Most research on posture and respiration focuses on supine versus sitting rather than standing specifically.
Standing Options
The TekRMD in indoor trim
How you achieve standing depends on your resources and situation:
Standing frames. The traditional option is a static frame that holds you in a standing position. These at their simplest are relatively inexpensive, widely available, and effective for delivering the weight-bearing benefits. The limitation is that you can't move while in them. The best ones will allow easy transfers on and off and will facilitate some form of exercise whilst up right.
Sit-to-stand devices. More sophisticated frames that raise you from sitting to standing without requiring transfers. These are easier for independent use.
Standing wheelchairs. Wheelchairs with integrated standing function. More expensive but offering mobility combined with standing capability. The emphasis is still on being a wheelchair with the facility of occasional standing. Typically, the user will be tilted back somewhat when fully standing, as this is necessary for stability.
Tek RMD. The TekRMD is a standing mobility device that allows you to stand and move around - essentially a standing platform you can drive. This combines the health benefits of standing with practical mobility, allowing you to stand while moving around your home or workplace.
Fundamentally, there is no such thing as a perfect product. Your choice may vary with the resources you have available and personal preferences.
How Much Standing Is Enough?
The research provides some guidance on duration and frequency:
30 minutes daily appears to be the minimum for most physical benefits (circulation, bowel function, pressure relief)
60 minutes daily is suggested for optimal mental health and psychological benefits
Consistency matters more than duration - regular shorter sessions outperform occasional longer ones
Distributed sessions may be more effective - multiple 10-minute sessions throughout the day rather than one long session
The UK Clinical Guidelines recommend 30-60 minutes per session with Grade A evidence.
Practical Considerations
If you're considering a standing programme:
Start gradually. Especially if you haven't stood for some time, begin with short periods (10-15 minutes) and build up. Orthostatic hypotension can be pronounced initially for some Individuals . Research suggests benefits are often perceived within the first week.
Monitor skin. Check the skin on your feet and legs after standing, especially early on. Weight-bearing on tissue that hasn't borne weight may cause redness or problems if you can't feel discomfort. Some devices, including the TekRMD, will have other points of contact with a device such as the shins. Although these areas should be very well padded, always check the skin and avoid using clothing that is creased in these areas, as that can lead to high-pressure.
Consider support. Some people can transfer and then stand independently in a standing frame; others need assistance. Ensure you have appropriate support for safe transfers and monitoring. Transferring on and off devices can be a source of risk. Ensure that you have the necessary equipment and support to accomplish transfers safely.
Be consistent. The benefits of standing accumulate with regular practice. A standing session once a week achieves little; daily or near-daily standing produces meaningful benefit. Compliance rates in research studies are high (74%), suggesting standing programmes are sustainable.
Summary
Standing after SCI isn't a cure for paralysis. It won't restore walking for most people. And some commonly claimed benefits - particularly bone density preservation - lack strong research support.
But for the benefits that are well-evidenced - contracture prevention, range of motion, spasticity reduction, psychological wellbeing - regular standing delivers real value. And the consistently reported benefits from patient surveys - improved circulation, reduced pain, better bowel function, fewer pressure injuries - suggest genuine quality of life improvements even where controlled trial data is limited. These aren't dramatic, headline-grabbing outcomes. They're incremental health maintenance - the kind of thing that's easy to neglect but accumulates into significant long-term benefit.
If you're not currently including standing in your routine, it's worth considering. Whether through a simple standing frame or a more sophisticated device like the Tek RMD, regular upright time is one of the more straightforward ways to support your long-term health after SCI. You can explore more information about the TekRMD on our website and contact us if you're looking for a quote or to try the product for yourself in your home environment.
Contact us if you'd like to discuss standing equipment options or how standing might fit into a broader rehabilitation programme. We're happy to help you think through what makes sense for your situation.
References
Walter JS, Sola PG, et al. (1999). Indications for a home standing program for individuals with spinal cord injury. *Journal of Spinal Cord Medicine*.
Dunn RB, Walter JS, Lucero Y, et al. (2001). Outcomes of standing programs with prolonged standing for individuals who use wheelchairs. *Physical Therapy*.
Glickman LB, Geigle PR, Paleg GS. (2010). A systematic review of supported standing programs. *Journal of Pediatric Rehabilitation Medicine*.
Gibson SK, et al. (2009). Effects of standing frame use in adults with SCI.
SCIRE Project. Clinical Guideline for Standing in Adults Following Spinal Cord Injury.
RESNA Position on the Application of Wheelchair Standing Devices (2013) and Position and Scoping Review on Supported Standing (2023).
UK Spinal Cord Injury Centre Physiotherapy Lead Clinicians/BASCIS/ACPIN. Clinical Guideline for Standing in Adults Following Spinal Cord Injury (2013).