Some children with CP are unable or have a limited ability to stand and walk. Standing devices in different versions 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?
When a child grows up it will typically be able to stand up with support at the age of 6-8 months.
By the age of 12 months the child will develop “pull to stand”, and from around 12 months and 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 total 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, stimulating to activity and participation, as well as giving the child the possibility to explore the world in the same way as their peers. These devices also have the intention of preventing or reducing secondary complication that might appear due to neurological dysfunction.
Evidence-based standing recommendations
I have dived into the research to get a better understanding of what the recommendations are and what the child can achieve from standing. In 2013, Paleg (among others) gave a systematic review focusing on dosage recommendation for supported standing. In general, there is a lack of evidence on this topic and more research should be done to conclude on effects. Nevertheless, these are the main findings in the review:
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 for 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.
Range of motion (ROM) is positively affected by standing, especially in the knee joints and hips, but also the ankle. It seems like the dosage of standing to affect ROM 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 seems to decrease in the lower extremity when standing and it seems to last for 35 minutes after the standing session finished. The review recommends the child to stand for at least 30-45 minutes to decrease muscle tone.
In addition to the above-mentioned benefits of standing, there are also some indications on standing to have a beneficial outcome on:
• Gastrointestinal function
• Respiration and circulation
• Muscle strength
• Mental function
• Skin integrity
What about 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 children with CP standing with support have an energy expenditure above 1.5 MET, meaning that positioning in a standing position may contribute to the accumulation of light physical activity and reduction of sedentary behaviour.
Another pilot study from Sweden confirms these findings for both static standing as well as dynamic standing (the Innowalk was used in this pilot). This indicates that standing contributes to breaking up sedentary behaviour and increases the level of light physical activity. According to the literature, this may have a positive effect on overall health.
Read more: What do we know about physical activity and cerebral palsy?
Standing is good for you!
Research indicates that standing up can affect your overall health positively. To sum up the findings above, you should:
• Start early!
• Stand often! Minimum five times per week
• The recommended daily standing time (min. 60 minutes) can be accumulated during the day
Choosing the right standing device
We as clinicians need to support our interventions on the best available evidence together with our clinical experience. We also need to be aware of what works for one family and child, might not work for another family and child. Meaning individual evaluation is continually needed in order to adapt our interventions.
This also needs to be taken into consideration when choosing the type of standing equipment for children. There are a lot of different devices on the market, and it’s up to us to decide the type of device from the child’s needs related to body function and structure, activity and participation, as well as environmental factors.
There might be a need to test different devices to find the best solution for the individual child – there is no “one fits all” solution.
That being said, new research currently in the works offer insights on the differences in static versus dynamic standing, indicating that a more dynamic approach might have more beneficial outcomes on:
• Respiration (Deeper)
• Increased temperature in lower extremities
• Increased ROM in hips
• Reduced muscle tone in the hips
• Quality of life (QOL)
This research is under publication and will be presented as soon as it is available.