Notes: Supported standing and use of standing frames

Updated: Scoping Review of Supported Standing

 McLean, L. J., Paleg, G. S., & Livingstone, R. W. (2023). Supported-standing interventions for children and young adults with non-ambulant cerebral palsy: A scoping review. Developmental medicine and child neurology, 65(6), 754–772.

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This scoping review identifies a range of benefits of use of standing  frames in young children from the age of 12-18 months

  • Maintenance of bone mineral density and contracture prevention outcomes were supported by the most experimental studies..
  • Qualitative evidence suggests that programmes are influenced by attitudes, device, child, and environmental factors.
  • Individualized assessment and prescription are essential to match personal and environmental needs.
  • Although experimental evidence is limited due to many factors, lived-experience and cohort data suggest that successful integration of standing programmes into age-appropriate and meaningful activities may enhance function, participation, and overall health.

What this paper adds

  • Supported-standing interventions may provide an important psychosocial and physical change of position.
  • Supported standing is not passive for those classified in Gross Motor Function Classification System level IV or V.

 

Dosing of supported standing programmes 

Paleg GS, Smith BA, Glickman LB. Systematic review and evidence-based clinical recommendations for dosing of pediatric supported standing programs. Pediatr Phys Ther. 2013 Fall;25(3):232-47.

PURPOSE: There is a lack of evidence-based recommendations for effective dosing of pediatric supported standing programs, despite widespread clinical use. :Using the International Classification of Functioning, Disability, and Health (Child and Youth Version) framework, we searched 7 databases, using specific search terms.

RESULTS: Thirty of 687 studies located met our inclusion criteria. Strength of the evidence was evaluated by well-known tools, and to assist with clinical decision-making, clinical recommendations based on the existing evidence and the authors' opinions were provided.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE: Standing programs 5 days per week positively affect bone mineral density (60 to 90 min/d); hip stability (60 min/d in 30° to 60° of total bilateral hip abduction); range of motion of hip, knee, and ankle (45 to 60 min/d); and spasticity (30 to 45 min/d).

Ozel S, Switzer L, Macintosh A, Fehlings D. Informing evidence-based clinical practice guidelines for children with cerebral palsy at risk of osteoporosis: an update. Dev Med Child Neurol. 2016 Sep;58(9):918-23.

AIM: To investigate the impact of new evidence for weight-bearing, bisphosphonates, and vitamin D and calcium interventions, towards updating the systematic review and clinical practice guidelines for osteoporosis in children with cerebral palsy (CP) published in 2011.

RESULTS: Six new articles underwent full-text review and data abstraction. These included one weight-bearing, three bisphosphonate, and two mixed intervention studies (bisphosphonate and vitamin D/calcium supplementation). Overall, there continues to be 'probable' evidence for bisphosphonates, 'possible' evidence for vitamin D/calcium, and 'insufficient' evidence for weight-bearing activities as effective interventions to improve low BMD in children with CP. There is 'possible' evidence for bisphosphonates in reducing fragility fractures.

INTERPRETATION: The grading of evidence to support the use of weight-bearing activities, bisphosphonates, and vitamin D and calcium supplementation in pediatric CP osteoporosis clinical practice guidelines remained the same

 

Macias-Merlo L, Bagur-Calafat C, Girabent-Farrés M, A Stuberg W. Effects of the standing program with hip abduction on hip acetabular development in children with spastic diplegia cerebral palsy. Disabil Rehabil. 2016;38(11):1075-81.

PURPOSE: Early identification and intervention with conservative measures is important to help manage hip dysplasia in children with a high adductor and iliopsoas tone and delay in weight bearing. The effect of a daily standing program with hip abduction on hip acetabular development in ambulatory children with cerebral palsy was studied.

METHOD: The participants were 26 children with spastic diplegia cerebral palsy (CP), classified at Level III according to the Gross Motor Function Classification System (GMFCS). Thirteen children stood with hip abduction at least 1 h daily from 12 to 14 months of age to 5 years with an individually fabricated standing frame with hip abduction.

RESULTS: At the age of 5 years, radiologic results of the study group were compared with a comparison group of 13 children with spastic diplegia CP who had not taken part in a standing program. The migration percentage in all children who stood with abduction remained within stable limits (13-23%) at 5 years of age, in comparison to children who did not stand in abduction (12-47%) (p < 0.01).

CONCLUSIONS: The results indicate that a daily standing program with hip abduction in the first 5 years may enhance acetabular development in ambulatory children with spastic diplegia CP.

IMPLICATIONS FOR REHABILITATION: Abnormal acetabular development is a problem related to mobility problems and spasticity muscles around the hip. The literature suggests that postural management and standing programs could reduce levels of hip subluxation and increase function in children with cerebral palsy. A standing program with hip abduction can be a beneficial to develop more stable hips in children with spastic diplegic GMFCS level III.

Townsend EL, Bibeau C, Holmes TM. Supported Standing in Boys With Duchenne Muscular Dystrophy. Pediatr Phys Ther. 2016 fall;28(3):320-9.

PURPOSE: To evaluate the safety, tolerability, and efficacy of supported standing in a small sample of boys with Duchenne muscular dystrophy (DMD).

METHODS: Four 12- to 15-year-old boys with DMD engaged in a home-based supported standing program for 6 to 12 months. A single-subject design was employed to examine muscle length. Bone mineral density was assessed at 4-month intervals using dual-energy x-ray absorptiometry.

RESULTS: Upright, sustained supported standing was tolerated in 3 of the 4 boys. Mean weekly stand times ranged from 1.3 to 3.3 hours. Improved hip or knee flexor muscle length was seen in 3 of the 4 boys. No boys showed improved plantar flexor muscle length or increased lumbar bone mineral density.

CONCLUSIONS: Findings offer preliminary empirical evidence addressing the safety, tolerability, and efficacy of standing in boys with DMD. Additional research with an emphasis on better program adherence is indicated.

Comment in Commentary on "Supported Standing in Boys With Duchenne Muscular Dystrophy". [Pediatr Phys Ther. 2016]