Clinical recommendations for supported standing programs for children with CP
Some children with CP are unable or have a limited ability to stand and walk. Standing frames of varying types are something almost all children with CP get acquainted with. But when and why should a child stand? And how often and for how long? And what type of device should be used?
Typical versus atypical motor development
Evidence-based standing recommendations
Is standing classed as physical activity?
Choice of standing frame
Typical versus atypical motor development
When a child grows, they will typically be able to stand up with support at the age of 6-8 months. Before the age of 12 months the child will develop “pull to stand”, and from around 12 months onwards the child will be able to stand independently and develop walking skills. These milestones give the child the opportunity to explore the world, which also stimulates skills like cognition, social interaction and communication which is vital for the child’s overall development and independence.
Children with cerebral palsy (CP) will experience a delay in motor milestones and some with a severe level of CP might not learn to sit, stand and walk independently.
Luckily, there are a lot of assistive devices in the market with the purpose of compensating for a lack of motor function to support the child in everyday living, encouraging activity and participation, as well as giving the child the possibility to explore the world in the same way as their peers. These devices are also used as an intervention to prevent or reduce secondary complications that might appear due to neurological dysfunction. Typical secondary complications that may occur in children who have limited ability to achieve independent standing and walking function include low bone density, fractures and contractures.
It is recommended that children with CP are supported by equipment in different positions based on age-appropriate motor milestones. Meaning, between 9-12 months of age, it is suitable for a child to be positioned in a standing frame to promote age-appropriate development.
Evidence-based standing recommendations
In 2013, Paleg et al. published a systematic review focusing on the benefits of standing and dosage recommendations for supported standing, and in autumn 2022 a new and updated systematic review was published.
The two articles emphasise that evidence to support standing is limited. Nevertheless, 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. Some recommendations are also highlighted in relation to dosage and expected effects:
Bone mineral density (BMD) seems to be positively affected when standing for 60 minutes a day, 5-7 days a week. There are some studies (on animals) showing that short sessions of 10-15 minutes for a total of 60 minutes per day could have equal or superior benefits to a single session lasting 60 minutes. The evidence also indicates that children who are not standing are at risk of low BMD. The literature also indicates that we should be aware of factors like nutrition, vitamin levels, other medicine negatively affecting BMD and overall physical activity level.
Passive range of motion (PROM) is positively affected by standing, especially in the knee joints and hips, but also the ankle. It appears that the dosage of standing to affect PROM should be at least 45-60 minutes daily. It is also recommended to start standing as early as the age of 9-10 months.
Spasticity/muscle tone seems to decrease in the lower extremity when standing and lasts for 35 minutes after the standing session finished. The review recommends that a child should stand for at least 30-45 minutes to decrease muscle tone.
In addition to the above-mentioned benefits of supported standing, there are also some indications on static standing having positive outcome on:
• Gastrointestinal function
• Respiration and circulation
• Muscle strength
• Mental function
• Skin integrity
It is known that people with CP have increased incidence of pain and there is a strong connection between misalignment and pain. Supported static standing has been reported both as a cause and a relief for pain. Change of position from sitting to standing can be pain-relieving.
Pain is an important issue and should always be evaluated in all positions. What is the cause of pain? And what can be done to reduce pain?
Is supported standing physical activity?
It is well known that people with CP are physically inactive compared to people without a disability. The consequences are lifestyle-related diseases in addition to secondary complications. Research actually found that children and adults with CP spend 76-99% of their waking hours being sedentary and less than 18% are engaged in light physical activities. A study from the Netherlands shows that in static standing, children with CP have an energy expenditure above 1.5 MET, meaning that positioning in a standing frame may contribute to the accumulation of light physical activity and reduction of sedentary behaviour.
A study from Sweden confirms these findings for both static standing as well as dynamic standing. This indicates that supported standing contributes to breaking up sedentary time and increases the level of light physical activity. According to the literature, this may have a positive effect on overall health.
Research indicates that supported standing may positively affect overall health. To sum up the findings above, children with limited or no ability to stand and walk independently should:
• Start with supported standing early!
• Stand often! Minimum five times per week
• The recommended daily standing time (min. 60 minutes) can be accumulated during the day
Choice of standing frame
As clinicians we need to support our reasoning with the best available evidence together with our clinical experience. In addition, we are required to work with families to find equipment that is suitable for both the child, the caregiver, and also takes environmental factors into consideration. We also need to be aware of what works for one family and child, might not work for another family and child. Meaning individual assessment is continually needed in order to adapt our interventions.
The same considerations are needed when searching for the most suitable standing frame for an individual child. There are many different devices on the market, and the clinicians should together with the family evaluate what type of equipment is most suitable and cover the child’s needs related to body function and structure, activity and participation, as well as environmental factors.
There might be a need to assess different types of equipment to find the best solution for each child – there is no “one size fits all” solution.
Development of new technology make it possible to choose between several types of standing frame. This may be traditional standing frames (prone or supine) or other types of devices with an electric sit-to-stand function. A more dynamic standing position is now also available with the Innowalk. The Innowalk offers mechanical sit-to-stand function and motor-assisted and repetitive movement of the legs in standing. The adaptable support system enables appropriate positioning and comfort.
Research indicates that dynamic standing in the Innowalk has positive impact on:
- joint mobility in the hips
- quality of life
- blood lactate
- gastro intestinal function
Learn more about the Innowalk here.
Mapping of needs
To assess what type of equipment for supported standing that is appropriate for the child and the family, we have gathered some questions relevant for mapping needs:
- What is the goal of supported standing?
- Where is it most appropriate for the child to stand?
- When does it best fit into everyday life for the child to stand?
- In which activities or situations might it be appropriate to integrate supported standing activity?
- Who will be responsible for assisting the child getting in/out of the device?
- Who is responsible for following up changes related to growth or changes in function that may have an impact on the use of the equipment and the need for adjustments?
In addition, there is a need for assessing the child's joint range of motion, muscle tone, misalignment, contractures and any pain issues. One should also obtain necessary measurements of the child to assess the right size of equipment.
A good assessment of the child's needs forms a good basis for trying out one or more types of equipment for standing. During the trial, it will be assessed whether appropriate positioning is achievable and to what extent the device meets the mapped needs of the child, the family and environment. In addition, it is very important to assess the child’s acceptance of supported standing and that the positioning is comfortable for the child.
Do you want to know more about CP? Read our resource page with answers to most of your questions regarding CP.
- Tornberg ÅB, Lauruschkus K. 2020. Non-ambulatory children with cerebral palsy: effects of four months of static and dynamic standing exercise on passive range of motion and spasticity in the hip. PeerJ 8:e8561 https://doi.org/10.7717/peerj.8561
- 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. doi: 10.1097/PEP.0b013e318299d5e7. PMID: 23797394.
- Lauruschkus, K.; Jarl, J.; Fasth Gillstedt, K.; Tornberg, Å.B. Dynamic Standing Exercise in a Novel Assistive Device Compared with Standard Care for Children with Cerebral Palsy Who Are Non-Ambulant, with Regard to Quality of Life and Cost-Effectiveness. Disabilities 2022, 2, 73-85. https://doi.org/10.3390/disabilities2010006
- Lundström P, Lauruschkus K, Andersson Å, Tornberg ÅB. Acute Response to One Bout of Dynamic Standing Exercise on Blood Glucose and Blood Lactate Among Children and Adolescents With Cerebral Palsy Who are Nonambulant. Pediatr Exerc Sci. 2022 May 1;34(2):93-98. doi: 10.1123/pes.2021-0098. Epub 2022 Jan 10. PMID: 35016158.
- McLean, LJ, Paleg, GS, Livingstone, RW. Supported-standing interventions for children and young adults with non-ambulant cerebral palsy: A scoping review. Dev Med Child Neurol. 2022; 00: 1– 19. https://doi.org/10.1111/dmcn.15435
- Tedroff K, Gyllensvärd M, Löwing K. Prevalence, identification, and interference of pain in young children with cerebral palsy: a population-based study. Disabil Rehabil. 2021 May;43(9):1292-1298. doi: 10.1080/09638288.2019.1665719. Epub 2019 Sep 17. PMID: 31526138.
- Jackie Casey, Andreas Rosenblad & Elisabet Rodby-Bousquet (2022) Postural asymmetries, pain, and ability to change position of children with cerebral palsy in sitting and supine: a cross-sectional study, Disability and Rehabilitation, 44:11, 2363-2371, DOI: 10.1080/09638288.2020.1834628
- Verschuren O, Peterson MD, Balemans AC, Hurvitz EA. Exercise and physical activity recommendations for people with cerebral palsy. Dev Med Child Neurol. 2016 Aug;58(8):798-808. doi: 10.1111/dmcn.13053. Epub 2016 Feb 7. PMID: 26853808; PMCID: PMC4942358.
- Verschuren O, Peterson MD, Leferink S, Darrah J. Muscle activation and energy-requirements for varying postures in children and adolescents with cerebral palsy. J Pediatr. 2014 Nov;165(5):1011-6. doi: 10.1016/j.jpeds.2014.07.027. Epub 2014 Aug 20. PMID: 25151195; PMCID: PMC4440582.
First published 29.05.2019.
Rikke Damkjær Moen brings many years of experience as clinical physiotherapist to the Made for Movement team. Her mission is to ensure that everybody, regardless of mobility problems, should be able to experience the joy and health benefits of physical activity. As our Medical Manager, Rikke is passionate about sharing knowledge so that individuals with special needs, families, and clinicians can discover the possibilities and solutions provided by Made for Movement.
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