Guidance on Assisted Standing for Children with
Cerebral Palsy
Sue Bush1, N Daniels2, J Caulton3, A Davis4, J Jex5, G Stern6, E William7, S Bostock8,
1
Highly specialist paediatric physiotherapist, Northwick Park Hospital, 2Lecturer in Occupational Therapy,
University of Derby, 3Lecturer in physiotherapy, University of Keele, 4Paediatric physiotherapist, 5Clinical
specialist physiotherapist, Active Design Ltd. 6Senior Bobath tutor, freelance lecturer and clinical consultant,
7
Independent paediatric physiotherapist, 8Manager Equipment and ABI / ADP, Novita Children's Services,
171 Days Rd, Regency Park, South Australia 5942
All correspondence to Sue Bush: suebush2001@yahoo.com
Abstract: This systematic review was written to provide an evaluation of the evidence that is currently
available to support the use of assisted standing for children with cerebral palsy. The conclusions drawn are
intended to inform the reasoning of the clinician and to identify topics that need further research.
As part of their programmes of treatment, physiotherapists often assist children with cerebral palsy to stand.
This can be achieved in various ways but most commonly using assistive technologies known as standing
supports, standing frames or standing devices. Claims have been made that assisted standing can increase
bone density, improve hip joint development, reduce muscle spasticity, maintain muscle length and prevent
contractures. Physical benefits are also believed to include improved circulation, respiratory, bowel and
bladder function whilst psychological and social benefits are believed to come from the increased self esteem
derived from a child’s ability to interact with peers at eye level.
Despite the extent to which assisted standing is used by clinicians published scientific evidence to adequately
support these potential benefits is limited. No published guidance is currently available to inform the clinical
reasoning of prescribers of standing programmes. There appears to be a lack of consistency in relation to
desired treatment outcomes, timing, type of equipment and optimal positioning, by those who prescribe
standing programmes.
Background
The Gross Motor Classification System, (Palisano et
al,1997) which classifies the functional abilities of
children with cerebral palsy, indicates that those
children with levels II –V may require some
assistance to achieve or maintain a standing
position.
As part of a programme of treatment,
physiotherapists often assist children with cerebral
palsy to stand. This can be achieved in various ways
but most commonly using assistive technologies
known as standing supports, standing frames or
standing devices. A wide range of these products
are commercially available, each with varied
features and designs, to offer the standing support
necessary to meet the diverse needs of this client
group. The clinical benefits that can be derived from
this intervention are believed to be wide ranging and
include a number of physiological, psychological
and social benefits.
Gudjonsdottir (1997) discussing the clinical
implications of musculoskeletal development in
cerebral palsy, advised that the aim of physiotherapy
should be to slow down the progression of
deformity. Preventing contractures was seen to be
important in enhancing movement and weight
bearing activities and promoting anti-gravity
postural control, active movement and weightbearing. Preserving good alignment helps to
counteract the deforming forces, maintain muscle
length, promote normal joint formation, and delay
bone loss.
Pountney (2002) includes the developmental
position provided by postural support in standing,
as part of a comprehensive programme of 24 hour
positioning. This could encourage the development
of a higher level of postural ability to prevent the
development of damaging asymmetrical postures.
Claims have been made that assisted standing can
increase bone density (Stuberg 1992), improve hip
joint development (Campbell, Palisano and Van der
Linden 1994), reduce muscle spasticity, maintain
muscle length and prevent contractures (Edwards
2001, Stokes 1998. Physical benefits are also believed
to include improved circulation, respiratory, bowel
and bladder function (Bromley 1998)whilst
psychological and social benefits are postulated to
relate to increased self esteem derived from a child’s
ability to interact with peers and family members at
eye level.(Brogren 1995)
A consensus statement on postural management
(Gericke, 2006) advised that children in GMFCS IVV should start postural management in lying as soon
as appropriate after birth, in sitting from 6 months,
and in standing from 12 months. This document was
unfortunately published without references to
support the advice given.
3
Guidance on Assisted Standing for Children with Cerebral Palsy
Despite the extent to which assisted standing is used
by clinicians published scientific evidence to
adequately support these potential benefits is
limited. No published guidance is currently
available to inform the clinical reasoning of
prescribers of standing programmes. Assessment
tools and outcome measures to aid the prescription
of supported standing are available, but rarely used
in practice (Wintergold, 2008). Hence, there appears
to be a lack of consistency in relation to desired
treatment outcomes, timing, type of equipment and
optimal positioning by those who prescribe
standing programmes.
A systematic review was subsequently undertaken
to provide an evaluation of the evidence that is
currently available to support the use of assisted
standing for children with cerebral palsy. This
review is not intended to be prescriptive but to
inform the reasoning of the clinician and to identify
topics that need further research.
Method
The following key words were used to search for
published literature: child development, cerebral
palsy, weight bearing, hip dislocation, hip dysplasia,
children, adolescence, paediatrics, postural
management, standing, standing support, stander,
standing frame, tilt table, upright, supine, prone,
load, positioning, skeletal alignment, bone mineral
density, education, environmental interaction,
function, activities of daily living, comfort, orthoses
(orthotics), contracture management, spasticity,
bladder function, constipation, physiological
functions, cognition, quality of life, blood pressure,
respiration.
The following sources were used to carry out this
search: CINAHL, Medline, Pub Med, Google
Scholar, Cochrane library, Pedro, Embase and a
manual search of the Journal of the Association of
Paediatric Chartered Physiotherapists.
This search found a total of 109 papers. The title and
abstract of each article was reviewed using the
following
Inclusion Criteria:
1. Participants with cerebral palsy (emphasis on
children 0-19)
2. Research involving standing (quantitative or
qualitative research)
Exclusion criteria:
1. Papers relating to postures other than standing
2. Papers relating to conditions other than cerebral
palsy e.g. degenerative conditions and spinal
cord injury. (This decision relates to the different
physiology of these conditions and different
4
psychosocial circumstances where independent
standing has been established but then lost)
This resulted in a total of 56 papers being identified
as suitable for full review. The reference list of each
article was also reviewed to ensure all relevant
literature was identified.
An international panel of 8 experienced clinicians (7
physiotherapists, and 1 occupational therapist),
carried out the review. The reviewers responded to a
request placed in the APCP journal. Two reviewers
had carried out research in this field, others had an
interest in the subject. Consistency among the
reviewers was established by using relevant CASP
tools to review specimen papers and comparing
results. After this exercise reviewers were randomly
allocated a range of papers. To evaluate these, each
article was stratified to categorise the level of
evidence (Sackett 2000) and an appraisal tool (CASP
2007) appropriate to the type of study was used to
guide the review and to maintain consistency
amongst reviewers.
RESULTS
The literature has been reviewed and collated in the
following categories:
• Function
• Bone mineral density
• Hip development
• Neuromuscular effects
• Physiological effects
• Perceptions of users of standing frames
FUNCTION
Woollacott and Burtner (1996), in an observational,
longitudinal study (Sackett level 2B) to understand
the development of neural and musculoskeletal
contributions to the development of stance balance
control, found that typically developing children
who were asked to stand on a moveable platform
with a crouched posture similar to that seen in many
children with cerebral palsy showed EMG responses
to platform perturbations that approximated to
those of the children with cerebral palsy. In this
study joint alignment was seen to influence muscle
responses and there was increased frequency of coactivation of both proximal-distal and agonistantagonist muscles induced by the crouched
posture. (The authors do not state how many
children were studied in this research)
Children with cerebral palsy exhibit limited motor
behaviours, lacking the variation of their normally
developing peers, and suggesting a limited
repertoire of primary neuronal networks. Hadders
Algra (2000), in a discussion of neuronal group
selection theory, reviews the current knowledge and
Guidance on Assisted Standing for Children with Cerebral Palsy
theories of movement acquisition and advocates
therapy that extends sensorimotor experience for
the young child with cerebral palsy by means of the
application of variable postures to counteract the
infant’s propensity for stereotypical activity.
Although therapists have reported improved
functional position to be the highest priority for use
of a standing support (Wintergold et al, 2008),
studies that have evaluated the effect of positioning
on a child’s function are scarce. Published literature
ranges from dated single case studies (Ivey et al
1981, Cohen 1978) to low quality randomised
control trials. (Miedaner and Finuf 1993, Kramer et
al 1992)) and one cohort study (Noronha et al 1989).
Noronha et al (1989) found no significant difference
in the time required for ten boys with spastic
diplegia to complete the Jensen Hand Function Test
when comparing upper limb activities in sitting and
standing although did record a faster time for
feeding activities whilst the children were
positioned in a standing frame. Miedaner and Finuf
(1993) found positioning in adaptive equipment to
improve the outcome of psychological testing in
67% of cases using a sample of twelve children with
a diagnosis of spastic quadriplegia or diplegia.
However only one child in the study used a
standing frame.
It may not be the use of a sitting or standing position
alone which affects the outcome but the features of
the specific equipment and the position it enables a
child to achieve; for example the distance between
the shoulder girdle and the table top. The angle of
tilt of the standing frame may influence postural
tone, e.g. forward tilt may increase flexor activity
around the thoracic spine and shoulder girdle and
this may also have an impact on function.
Appropriate assessments should therefore be used
to assist this decision making process.
Case studies have anecdotally found the use of a
standing support to improve upper limb function
(Ivey et al 1981, Cohen 1978) whilst studies that have
used objective measures to record this outcome have
reported inconclusive results (Miedaner and Finuf
1993, Kramer et al 1992 Noronha 1989)
Summary -function
The lack of research carried out in this area, the age
of published studies and the use of small samples
makes conclusions difficult to draw in relation to a
child’s function in standing. Therapists should
therefore be aware that for each individual child
positioning may have an impact on function and
therefore analyse each task in accordance with an
individual child’s needs
BONE MINERAL DENSITY AND STANDING
Bone mineral density (BMD) is reported to have a
positive correlation with bone strength and has been
used as a predictor of fracture risk in adults
(Marshall 1996: WHO 1994). It is reasonable to
assume children with reduced bone mineral density
are more likely to fracture than their peers with
typical age related BMD. Henderson (1997) noted
that fracture rates were similar between children
with spastic quadriplegia despite a sedentary
lifestyle and lack of exposure to traumatic events
compared with typically developing children. This
section does not intend to review factors affecting
BMD in children with cerebral palsy. However, the
literature pertaining to the influence of static and
dynamic standing on BMD, the angle of standing
balance and also post fracture protocols is reviewed
within this section
Static standing
Stuberg’s frequently referenced paper which
investigated the relationship between BMD and
standing
has
influenced
the
paediatric
physiotherapy community since its publication
(Stuberg 1992). He stated that 1 hour of static
standing five times a week was necessary to retard
loss of BMD.
However these findings were preliminary and final
findings have never been published. This
publication also gave limited detail of the study
design, sample and type of data collected making it
difficult for reliable conclusions to be drawn or for
the study to be replicated. Many of the conclusions
of Stuberg’s review are extrapolated from research
on animals, adults and healthy athletes.
Some confusion also exists regarding the
discontinuation of a standing programme and its
effect on BMD. Stuberg (1991) suggested that BMD
was reduced following an interval of 8 weeks. It was
later reported that a break from standing over a
period of at least 8 weeks does not significantly
decrease BMD as measured by absorptiometry
(Stuberg et al 1991).
A more recent study by Caulton et al (2004) aimed to
determine whether 50% longer periods of standing
in either upright or semi-prone standing frames
would lead to an increase in vertebral and proximal
tibial bone mineral density of 26 non-ambulant
children with cerebral palsy. A 6% mean increase in
vertebral bone mineral density was found in the
intervention group, but the tibial site showed a
small negative change of -0.8% compared with the
control group. There was no description of the angle
at which the therapists chose to stand the children in
either group or of the knee joint positions which
5
Guidance on Assisted Standing for Children with Cerebral Palsy
may affect the tibial measure. Standing in the
intervention group ranged from an average weekly
duration of 219 minutes to 675 minutes per week.
This thorough piece of work raises issues regarding
how much standing may be needed to influence
bone density in the lower limbs.
Summary - static standing on BMD
Static standing may be useful to improve vertebral
bone density and maintain long bone density but
duration and frequency still seem to be open to
debate.
Angle of stand and weight bearing
There is some, albeit limited, evidence that angle of
standing affects the amount of weight borne
through the feet. Curtis (1989) studied 13 children
with cerebral palsy who were able to stand and walk
with aids, and found that they bore most weight
standing in an upright standing frame. However no
child transmitted more than 75% of their weight
through their feet in any frame. Miedaner (1990)
investigated the effect of angle of stand on 23
children with cerebral palsy, none of whom could
independently ambulate. The results (published as
an abstract) demonstrated that children who had
good head and trunk control bore most weight
through their feet in an upright stander but that
those who lacked head and/or trunk control bore
most weight at 20° prone angle (i.e. 20° from
perpendicular).
A recent study by Kecskemethy (2008) found
variability in weight bearing during stands in 20 nonambulatory individuals with quadriplegic cerebral
palsy (aged 6 -21 years) and between standers with
loads ranging from 37 -101% of body weight,
measured through footplates with axial load cells.
Summary - angle of standing
Consideration should be given to the angle of
standing where weight bearing is a goal of assisted
standing.
Dynamic standing
It is well known that ambulant children with
cerebral palsy have increased bone mineral density
(BMD) compared to those who are severely
involved (Wilmshurst et al 1996, Henderson et al
2004). Wilmshurst et al (1996) found that
reduced broadband ultra sound attenuation was
associated with the degree of immobility and
reduced weight bearing. Although this paper is not
directly related to standing it is indicative that
dynamic activity may be required to improve bone
quality.
Two studies have investigated dynamic standing in
6
children with cerebral palsy. The first was a small
study of 4 children with ‘severe’ cerebral palsy
(Gudjonsdottir and Stemmons Mercer 2002). It
examines how two types of prone stander (one
conventional, one offering intermittent transfer of
weight through left and right feet) affected bone
mineral density. Standing was for an eight week
period for 30 minutes daily, 5 days a week. Two
children stood in a conventional stander and 2 in the
dynamic stander. BMD in the femur and lumbar
spine was measured by dual energy x-ray
absorptiometry (DEXA).Three of the four children
showed increased bone density in the distal femur
on both sides. Two increased their lumbar BMD (1
control and 1 intervention). Increases were greater in
the femur than the spine. The authors concluded
that, with no adverse effects noted, the maintenance
and improvement in BMD using the standing
programmes is considered a favourable result.
Ward et al (2004) investigated low magnitude
mechanical loading in children with disabling
conditions (some of whom had cerebral palsy) who
could stand independently but had limited mobility.
Children were randomised to standing on an active
or placebo plate for 10 minutes a day, five days per
week, for six months. Spinal and tibial volumetric
trabecular BMD was measured by 3-D QCT.
Compliance with the protocol was 44%. The
intervention group showed increases in tibial BMD
whilst the control group showed a mean decrease.
Increases in spinal BMD were greatest in the
intervention group but this was not significant. (p =
0.31) However it may be clinically relevant for
maintenance of spinal BMD. The outcome of this
study is promising for future practice.
Summary - dynamic standing
Activity in supported standing may not only
improve postural control but may also improve
BMD.
Results from Ward’s study suggest dynamic stimuli
during standing may be the way forward when the
goal of standing is to improve BMD. The time for
standing could possibly be significantly reduced.
However since motorised dynamic standers are not
currently available in the UK continuation of
conventional standing as a means of maintaining
BMD seems appropriate
Research is warranted into the effects on BMD of
using dynamic activities in standing (e.g. targeted
training). In addition, development of a tool for
measuring weight bearing while standing is needed
to facilitate comparison of equipment and
orientation of standing frame
Guidance on Assisted Standing for Children with Cerebral Palsy
Standing Post Surgery/Fracture
Bones that have been immobilised with continual
lack of weight bearing are weaker and more at risk
of fracture or re- fracture due to further bone
mineral loss. (Sturm et al 1993) Care when handling
and positioning in standing is therefore essential. It
is necessary to weigh the potential risk of fracture or
re fracture with the desire to improve bone mineral
density by weight bearing (Chad et al 1999)
Sturm et al (1993) identified several femoral
fractures after hip spica immobilisation for hip
operations. After cast removal two- person lifting
was carried out for two months; all patients were
gradually progressed from lying to sitting and kept
non-weight-bearing for six weeks. Partial weight
bearing with assistance or in a prone stander was
then commenced. No indication of the actual
positioning or timing for the standing protocol was
given.
A further study that investigated complications
following osteotomies (Stasikelis et al 1999) noted
that most of the children used prone or supine
standers following surgery, while in their casts. No
details of timings were given. Post cast removal
protocols were not clearly identified other than
prone or supine standing in addition to physical
therapy.
Summary -standing post surgery
Varying approaches to standing post surgery make
it very confusing for the physiotherapist therefore
close consultation with orthopaedic colleagues is
required .
THE RELATIONSHIP BETWEEN SUPPORTED
STANDING AND HIP DEVELOPMENT
Normal Hip Development
Children who have bilateral cerebral palsy are born
with normal hips, but often have over activity of
dominant muscle groups around the hip joint. (Beals
1969, Gudjonsdottir 1997)
Gudjonsdottir (1997) advises that weight-bearing
activities are crucial for the congruent development
of the femoral head and acetabulum.
Typically developing children kick, crawl, pull to
stand and cruise. These movements strengthen the
action of the hip abductors at their attachment to the
greater trochanter, and induce a change in the
biomechanical forces, altering the internal structure
of the femoral neck. This causes the angle of the
femoral neck to shaft to decrease and engage with
the acetabulum. (Siffert 1981)The most important
loads are weight-bearing and muscle tension
applied in the appropriate magnitude and direction.
Early changes to hip architecture have also been
identified by Scrutton and Baird (1997, 2001) who
highlighted the need for early surveillance and
intervention to prevent hip subluxation.
The APCP (2001) published guidance for the
prevention and management of hip dislocation in
children with cerebral palsy. In section 1.3
‘Treatment’ advised on current evidence that
`Weight-bearing programmes can improve joint
formation and reduce osteoporosis, and that
children should weight bear for 60 minutes 4 to 5
times a week to enhance bone development secure
hip joint. This advice is based on the
recommendations of Stuberg discussed above.
NEUROMUSCULAR EFFECTS
Tremblay et al (1990) demonstrated a lowered EMG
and torque at the ankle, measured during passive
movement (at 30 and 60 cycles per second) after 30
minutes of stretch to triceps surae using a modified
tilt table. These effects were statistically significant
(p<0.05) Capacity to voluntarily activate the plantar
flexors was also significantly improved(p<0.05),
although activation of dorsiflexors was not affected.
Effects were shown to last for 35 minutes but no
measurements were taken after this.
Richards, Malouin and Dumas (1991) showed
decreased resistance to passive movement,
decreased EMG response and improved voluntary
activation of triceps surae in children with cerebral
palsy; however this did not translate into an
observable functional change in gait when
measured over one session.
Summary -neuromuscular effects
These two studies involved only small numbers of
subjects and one session of muscle stretch. Further
research needs to be carried out to determine how
long the neuromuscular effects last for and whether
repeated sessions can produce any change in
function.
EFFECTS ON PHYSIOLOGICAL FUNCTION
The only evidence for respiratory effects of
standing is a single case study which reported
improved breathing and reduced stridor, but no
objective measures were used (Ivey et al 1981).
Anecdotally, clinicians report improvement of
bowel function in children with cerebral palsy as a
result of supported standing but no research could
be found to support this.
In a small study of 8 children with profound
physical difficulties and 22 age and height matched,
7
Guidance on Assisted Standing for Children with Cerebral Palsy
normally developing controls, Stannard (2002)
found the postural changes involved in being
passively positioned in standing equipment resulted
in changes in heart rate in both groups. This
persisted in the control group but not in the disabled
children who experienced a drop in systolic blood
pressure. A ‘substantial proportion’ of the disabled
children were found to have arrhythmias affected by
postural change. This study suggests that if a child’s
cardiovascular system is compromised, or if
arrhythmias are known to be present, special care
should be taken when introducing standing.
PERCEPTIONS OF USE
A qualitative study for the MHRA (Daniels et al
2004, Daniels 2005) highlighted the advantages and
potential limitations of designs and features of
standing frames, and assessed their ease of use and
acceptability by users, therapists and carers. Twelve
children, aged 8-14 years (10 with spastic
quadriplegia, 2 with other presentations) trialled
eleven different standing frames (prone, supine or
multi-positional) in twenty three trials; twenty at
school and three at home.
Opinions of children and therapists regarding use of
standing frames were gathered regarding foot, knee
and pelvic supports as well as comfort, access,
manoeuvrability, stability and weight-bearing.
The children all enjoyed standing and ten
commented that they enjoyed using their current
standing frames; five liked the colour, six liked the
comfort. Two children disliked standing due to
discomfort/knee pain. The children preferred
frames that were given to them during the trial to
their regular standing frames. Six children said they
would like to move around more in their regular
frame and four said that they would like to improve
the comfort of their own frame.
Therapists evaluated the standing frames and gave
their preferences considering: posture/position,
ease of access and positioning, support, standing
time tolerated, adjustability, aesthetics, possibility
for child to control own position, transportability.
Carers expressed their opinions using the same
criteria. The research noted limited resources (such
as time restrictions and financial restrictions), as
playing a part in the prescription of equipment.
The children, carers and therapists expressed
preferences, which should be considered when
providing standing frames, to optimise and
maximise benefits of standing, within the available
resources
Summary - perceptions
Good postural alignment and comfort were found to
be the key to the successful use of standing frames
and those with multiple adjustments received
positive feedback.
Optimal prescription is individual to suit the needs
of the child, and therapist awareness of the different
available features is essential.
Discussion
From this review it will be evident that there is
some, albeit limited, evidence to support the use of
assisted standing for children with cerebral palsy to
maintain BMD and produce short term changes in
muscle tone. If it is possible to gain a well aligned
standing position with adequate weight –bearing it
may be possible to maintain or improve the integrity
of the hip joint in non-ambulant children as a part of
24 hour postural management.
Support for physiological and psychosocial effects is
anecdotal and remains unsupported by any good
quality research.
For improving BMD Stuberg (1992) suggested 60
minutes, 4-5 times per week for maintaining bone
density, although as previously stated this
recommendation is based on research in animals
and preliminary results from a piece of unpublished
research.
Tremblay (1990) and Richards (1991) and colleagues
produced short term changes in muscle tone with 30
minutes of stretch to triceps surae. Clearly
positioning that produces adequate stretch will be
crucial if the goal is to reduce muscle tone. The
timing of the stand should be considered so that the
child has an opportunity to make use of this
temporary reduction in tone for improved
functional activity either within or outside of the
standing frame.
Where improvement in the integrity of the hip joint
is the primary goal there should be particular
attention to alignment and weight bearing. The
selection of a standing support which allows some
movement at the hip joint is also advocated.(Green
1993)
Consideration of the primary goal for standing is
essential as timing, positioning and equipment may
vary according to that goal. Treatment goals should
therefore be clearly defined and reviewed regularly
when designing and implementing a standing
programme.
In order to achieve their goals clinicians need an
8
Guidance on Assisted Standing for Children with Cerebral Palsy
awareness of a range of equipment and should be
prepared to carry out assessments using different
standing supports to identify the best equipment for
each individual. Children’s views should be sought
at all stages of this process particularly with regard
to comfort in standing.
There is a clear need for further research on all the
effects of assisted standing in order to give a more
solid evidence base on which to base clinical
practice.
Conclusion
Physiotherapists have been using standing supports
to achieve standing for children with cerebral palsy,
aiming for a variety of results. Evidence is scant but
supports the use of standing aids for goals of
improving BMD, altering muscle tone and
improving hip joint development. The use of
assisted standing to obtain other effects has little
evidence to support it. Clearly further research is
required in order to give better guidance on
standing positions, length of time in standing and
frequency of standing. Also research is needed to
establish the effects of standing on physiological and
psychosocial functioning.
Therapists should define goals, consult the children
at all stages and choose assessments and outcome
measures to inform the efficacy of using standing to
achieve these goals. These goals should be reviewed
regularly and therapists should be aware of the
variety of equipment that is available and best able
to achieve goals.
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