Clinical Case Studies
Standing Strong:
An update on passive standing programs for children
By Ginny Paleg, MS, PT
Therapists shouldn't forget to teach children the skill of standing and may need to change passive standing program parameters to achieve their goals. Dynamic, or active, standing is probably better than passive standing.
Why Standing?
Placing children with cerebral palsy (CP) and developmental delays (DD) on rigid upright or reclined positioning boards was first documented in the 1950s. Journal articles began appearing in the 1970s suggesting that spending time upright or semi-upright could benefit children who could not assume or maintain this position on their own.
The first standers were designed by professionals working in large institutions. These dedicated therapists and educators noticed that children who were unable to stand or walk enjoyed being in the standing position. Medical, health and behavioral benefits were also noted.
Today, most standers are used by children with gross motor dysfunction in their homes and classrooms. Why do we use standers? What is the evidence basis? What are appropriate lengths of sessions? What goals can be achieved? How can we make this activity more fun?
In his cornerstone article on standing published in 1992, Wayne Stuberg recommended 45 to 60 minutes of standing a day to maintain bone density in children with CP. Stuberg also recommended standing two or three times per day for the duration of 45 minutes to control lower extremity flexion contractures.
In a separate study, Stuberg looked at 20 children with CP who were nonambulatory and using standing programs in their educational setting. He studied children who stood in school on three to four days per week for 30 minutes, and compared them with children who stood on four to five days per week for 60 minutes. Stuberg's study also evaluated these children when they went home over the summer and did not stand at all.
He found that bone density decreased in the children who did not stand at all and in those who had stood for 30 minutes per day. Bone density was maintained in the children who stood for 60 minutes per day.
Dr. Stuberg looked to animal models and research to determine the physiological benefits of standing. These studies showed that cycles of loading and unloading (dynamic standing) stimulated the osteoblasts to lay down new bone more than did static standing.
Expanded Knowledge
Newer articles have shown that torsion, or twisting, while loading is the best way to maintain and build bone density. We may be able to improve the benefits of standing programs by using equipment that allows for loading and unloading as well as twisting.
In a traditional supine or prone stander set at 80 degrees, only about 20 percent of the body weight is translated through the femur. A child placed in an upright stander in such a way that the trunk is unsupported may begin to approach a level of weight bearing through the long bones that a typically developing child would exhibit. Perhaps using a suspension harness system is a better alternative to get more weight bearing through the legs as well as more muscle activity.
All this focus on bone density begs the question: Is this an important clinical issue? The answer is yes. Brunner and Doderlein (1996) published a retrospective study in the Journal of Pediatric Orthopedics Part B on 37 patients with CP having sustained 54 fractures with no evidence of significant trauma.
Can we affect bone density with a static standing program? This question has not been adequately addressed. We can improve bone density in children with CP by introducing a weight bearing physical activity program. Chad (1999) reported that, after an eight-month physical activity intervention in children with cerebral palsy, the children showed an increase in femoral neck and total proximal femur bone mineral content.
Participation in a weight bearing program may help prevent acquired hip dislocation in children with CP. In 1959, Phelps published a study on 100 children with CP who had not borne weight before the age of 4 years and compared them to 100 normally developing children and children with CP who had. He found that 25 percent of children in the non-weight bearing group had coxavalga, compared to between 3 and 4 percent in the weight-bearing group. He concluded that the acquired dislocation of the hip in children with CP appeared to result from coxavalga due to late weight bearing, along with spasticity and contracture.
In Conclusion
While many caregivers, medical and educational professionals who work with children with CP and other developmental delays recommend and use equipment-based standing programs, the evidence for these programs is still growing. There is a strong need to validate the practices we engage in on a daily basis. In the absence of strong support and proof, third party payers will not fund this equipment and children will lose out on the opportunity to benefit from achieving the upright, weight bearing position that they can attain in no other way.
It is incumbent upon therapists to keep high standards of documentation, and compile the results in support of standing programs for children with CP and developmental delay. In the absence of large-scale randomized controlled studies, we must rely on the literature that currently exists. Clearly, equipment-based standing programs can benefit children who cannot yet walk or stand independently.
It is the author's intention that the references sited and discussed in this article will help clinicians in choosing the best protocol and equipment. Ultimately, all children with disabilities should be exposed to upright standing, to help them move along the continuum from static to dynamic, to supported standing, and then to independent and functional standing.
Ginny Paleg is an NDT Certified Pediatric PT in Silver Spring, MD. She works part-time for Montgomery County Public Schools Early Intervention and is nearing completion of her DScPT at the University of Maryland. She teaches continuing education courses on pediatric gait training, standing programs, power mobility, seating, positioning and spasticity management. She can be reached at ginny@paleg.com
FAQ on Standers
Why do we use standers?
To decrease spasticity, improve head and trunk control, increase arousal, decrease constipation, improve range of motion.
What is the evidence basis?
Case studies, small case series and small controlled studies.
What are appropriate lengths of sessions?
45 to 90 minutes per day (does not all have to occur at one time); all weight-bearing activities (such as using a gait trainer) count toward this total.
What goals can be achieved?
Measurable goals include reducing angle of stander (toward full upright), improving hip flexor and heelcord PROM and ability to self propel a model that has large wheels, like a wheelchair.
How can we make this activity more fun?
Make sure there are appropriate toys of the tray, use stander to include children in group activities, use a self-propelled stander. Since dynamic standing may be the best option, try using a suspension harness to teach active standing with movement as well as sit to stand and stand pivot transfers.
Published in Advance News Magazines |
