Standing for Consciousness: A Practical Guide to Using Tilt Tables and Standing Frames for Patients with Disorders of Consciousness After TBI

As clinicians, we're always looking for ways to promote recovery and improve outcomes for our patients with severe TBI. One intervention that's been gaining traction is the use of standing frames and tilt tables for patients with disorders of consciousness (DoC). But what does the evidence actually say? And how can we implement this in our practice? Let's dive in. ### The 'Why': Rationale for Standing The idea behind using standing frames and tilt tables is to provide a form of sensory stimulation and weight-bearing that can help to improve arousal and awareness. The physiological effects of mobilization, even passive mobilization, are well-documented. As Nazwar et al. (2023) point out, prolonged immobilization can lead to a host of complications, including muscle breakdown, bone resorption, and cardiopulmonary issues. Early mobilization, on the other hand, has been shown to improve physical function, reduce length of stay, and decrease the incidence of delirium. When it comes to patients with DoC, the rationale for standing is twofold. First, it provides a powerful proprioceptive and vestibular stimulus that can help to activate the reticular activating system, the part of the brain responsible for arousal and wakefulness. Second, it provides a form of weight-bearing that can help to maintain musculoskeletal integrity and prevent secondary complications. The systematic review by Ng et al. (2021) found that head-up tilt is commonly used in rehabilitation with the aim of improving consciousness, and that there is some evidence to support this practice. ### The 'How': Implementing a Standing Program So, how do we actually go about implementing a standing program for our patients with DoC? The key is to start slow and be systematic. The ICU Mobility Scale, as described by Nazwar et al. (2023), provides a useful framework for progressing mobility, with standing being a key milestone. Here are some practical tips for getting started: * **Patient Selection:** Not all patients with DoC are appropriate for a standing program. It's important to carefully screen for contraindications, such as unstable fractures, severe spasticity, or autonomic instability. The decision to start a standing program should be made in consultation with the interdisciplinary team. * **Equipment:** A tilt table is the most common piece of equipment used for this type of intervention. It allows for a gradual progression to an upright position, which can help to minimize the risk of orthostatic hypotension. Standing frames can also be used, but they may not be appropriate for all patients. * **Dosing:** The optimal dosing for a standing program is still a matter of debate. However, the systematic review by Ng et al. (2021) found that repeated passive standing on a tilt-table can improve consciousness. A good starting point is to aim for 20-30 minutes of standing, 3-5 times per week. The duration and frequency can be gradually increased as tolerated. * **Monitoring:** It's crucial to closely monitor the patient's vital signs and clinical status during and after each standing session. This includes heart rate, blood pressure, oxygen saturation, and level of consciousness. Any signs of distress or instability should prompt an immediate cessation of the intervention. ### The 'What': Evidence for Effectiveness Now for the million-dollar question: does it actually work? The evidence is still emerging, but it's promising. The systematic review by Ng et al. (2021) included 10 studies and found that there is some evidence that repeated passive standing on a tilt-table can improve consciousness. The two high-quality studies in the review found a large effect on consciousness. However, the authors caution that the overall quality of the evidence is low and that more research is needed. It's also important to note that not all studies have found a positive effect. A 2015 randomized controlled trial by Krewer et al. found that tilt table therapy did not improve outcomes in patients with severe DoC. However, this study has been criticized for its methodology, and the findings should be interpreted with caution. So, what's the bottom line? While the evidence is not yet definitive, there is a growing body of literature to suggest that standing frames and tilt tables can be a safe and effective intervention for patients with DoC after TBI. As clinicians, we need to be guided by the evidence, but also be willing to try new things and push the boundaries of what's possible. By carefully selecting our patients, using a systematic approach, and closely monitoring for adverse effects, we can give our patients the best possible chance of recovery.