PHOTO CAPTION: Getting family members to buy-in and carry over the standing program is key in achieving optimum outcomes.
As a physical therapist working with ages birth to 3 years, I am often the first person responsible for developing a standing program for young children who are affected by developmental delays. In Minnesota, therapists service these youngest children in their homes in their natural environment. Some services are done at day care when scheduling all the required visits in the child’s home is not possible. Regardless of where standing services are provided, matching a young child with appropriate standing equipment is critical to a program’s success. This article explores two of the most important questions in that equation: What is the best age for beginning a medical standing program, and what is the best stander for these little ones who are first beginning to stand?
Make an Informed Purchase
The discussion should begin by surveying the technologies on the market, meant to promote standing and gross motor development. Many parents will purchase exersaucers and jumper-saucers that are widely available and claim to help stimulate motor skills. The manufacturers behind some of these devices say they may be used with children as young as 4 months of age. When looking at normal development, however, children aren’t pulling to stand on their own until 8-9 months. Those tiny bones and muscles were not intended to stand for prolonged periods and jump at 4 months. In fact, too much container play seems to be contributing to some children showing delays in their gross motor skills. As an early intervention PT, I am working in the homes of children, and I see the reality that parents love these devices for “safe spaces” for their little ones so they can have some free time. If I sense that the family will not be open to discontinuing an exersaucer, I have found ways to limit their use through education and adjust the device to allow the children to work on flat-footed, safer standing in limited dosages.
Beginning to Stand
Standing children at age 9 months is my general guideline since this follows the trajectory of typical child development. Research supports the dosage of 60 minutes to help target the primary benefits of standing, including improved bone density, range of motion, and hip integrity.1 I work on using standers with students who have high muscle tone and lower tone. One of my primary goals with standing is to help students build strength, stamina, and the ability to support their body weight in standing, without the need for a stander. I assess their ability to get an hour of standing and weight-bearing during play around age 9 months with limited adult help. I might work with children who aren’t at the stage of pulling to stand yet but whose parents are very motivated to support them at a couch or other surface to stand throughout their day. In such cases, the child can get close to an hour of standing to improve his or her strength and stability. Other students require so much help and support that parents cannot realistically stand them up for more than a few seconds or a few minutes.
Once the need for a stander has been determined, the next step is to select the appropriate stander type. My own practice includes a storage room stocked with a variety of stander types, which provides the advantage of being able to try a number of variations with students. The availability of these devices also provides the opportunity to use a stander for a short length of time to help children progress a bit faster with supporting their body weight. Many children may benefit from a standing program but make enough progress over the next 6 months that they no longer need the standing device. These children are often the lower-muscle-tone, general-developmental-delay kids, and might include some who have Down syndrome and sensory issues that require building the capacity to do more in a weight-bearing position. For therapists who have children who need a standing program but do not have the loaning library of equipment, they may consider using leg immobilizers as a home program activity. These are reasonable and justifiable to order if working toward a standing goal and with the likelihood that stander use will be shorter-term. I have even combined leg immobilizers with an exersaucer when parents do not want to try other options. Longer-term standing programs would warrant getting a vendor involved and trying products so standing can be implemented as early as possible.
Choosing a Standing Solution
Several factors can influence stander choice. The type of support the student needs and how receptive a family will be to adding equipment into their home are two factors that have the greatest influence on stander choices I make. Many families are grieving a diagnosis, or are still in the stages of denial, thinking their child is going to outgrow their delays. For my part, I try to use a stander that will fit the child’s needs and be minimally intrusive for the family home. The important piece to keep in mind is getting the family to buy-in and carry over the standing program. A substantial amount of research demonstrates great outcomes with compliance.
Conversely, research notes that those who did not comply at the recommended amounts of time did not present with bone density changes, significant flexibility changes, or hip integrity changes. I can attest in my practice to observing tremendous strength improvements in 2-3 months’ time with implementation of standing programs that have good compliance.
Often, I have appealed to issues the child may be dealing with—that standing could help and be more important to the parent than bone density. Constipation can be an issue with children who aren’t moving enough. Although there are limited studies,2 I think most PTs can tell stories about how standers have helped children have more regular bowel movements while up standing. Another piece of standing is the social emotional piece. Children love being upright interacting with parents or siblings in a different way and seeing their world from a different perspective.3 Although this will not justify the need for a stander, it will help parents comply with a standing program.
Selection: Upright, Prone, or Supine
When making an equipment determination a therapist may need to decide between an upright stander or a prone stander. If the child has good head control and enough trunk control to keep themselves upright by leaning on their arms, I generally choose an upright stander; and there are a variety of standers in this category from which to choose. Once the initial adjustments are made to the stander, the family typically can learn to put their child into the stander with ease. I prefer a large tray and the ability to hook toys onto the tray or across the tray for entertainment. Finding a method to keep toys permanently across the tray also prevents children who like to drop their toys and clear the tray from losing all their toys. This, in turn, helps parents use the device with less frustration and boredom from their child.
A supine stander should be chosen when a child does not have adequate head and trunk control to be upright or slightly prone. This doesn’t mean you can’t work your way to an upright position; potentially, the child may be able to tolerate upright to slightly prone for shorter periods, but then fatigue. I tend to see this very often among children who are younger than age 1 year. Over time, many are able to build their capacity to spend some time in prone and, thus, gain the benefit of upper trunk and arm strength while standing. For this reason, I like to use a multipositional stander. There are many standers on the market that provide multipositions, but I prefer choosing one that allows you to move a child fluidly through supine, upright, and prone without removing the student or making support/component changes.
In recent years, there has been an emphasis on hip surveillance programs in the United States. Research from overseas is showing great potential to prevent and even make some changes with hip integrity with standing for 45-minute increments on a regular basis.4 Choosing a stander that allows the student to stand in 30 degrees of abduction bilaterally will help them grow into the product and meet the recommended guidelines for standing in 30 degrees of hip abduction to maintain hip integrity. When a child has any hip integrity issues or the potential to develop them due to muscle tone, imbalances and weaknesses, I prefer to start with a product that allows hip abduction. I used a stander with hip abduction for a young boy with Emmanuel syndrome who had significant hip dysplasia from birth. His orthopedist predicted he would need surgery by age 3 years. We started standing at age 9 months; he is now age 6 years and has improved and maintained his hip status enough to avoid surgery to this point. We know the outcomes are better with fewer surgeries later in life that children need hip surgery.5
Although the research is recommending standing with 30 degrees abduction, I tend to be more cautious with younger children who are age 9-18 months, beginning abduction with 5-10 degrees if the child seems able to tolerate it. Therapists should be careful with children who demonstrate increased muscle tone to make sure they have the range of motion to tolerate where the therapist starts them. Gradually increase the range every 2 weeks to make sure you gain confidence and compliance by families before increasing the hip range.
With very young children ages 9 months to 18 months, I do not generally go past 10-15 degrees of hip abduction, but this really depends on their body size as well. One caution I will mention about using any stander with abduction: If you sense the family needs time to learn how to use a stander, you can wait to show them the abduction feature. All the multipositional standers (or even supine standers) require learning how to bring the child from supine into a more upright position, and often require more trunk support such as a 4-point chest vest to help the child be successful in upright postures. Learning all these components first, setting up good compliance, and then building upon the routine, tends to set the stage for better long-term success.
Compliance Conquers All
Standers can make a tremendous contribution in reaching a pediatric client’s therapy goals. For these devices to truly make a difference, however, compliance by the child’s family is essential. When parents and family members invest themselves in a standing program their buy-in becomes clearly visible, manifesting when I see that a child has learned a new skill or improved their strength and endurance after using a stander over time. Furthermore, if I can help families and stakeholders in the child’s care connect the dots about how standing helped make these improvements happen, doing so offers tremendous professional gratification. After all, seeing positive results is what standing is all about. RM
Mary Miles, PT, DPT, ATP, has more than 30 years of experience as a pediatric physical therapist. She currently works with children and their families ages birth to 3 years in White Bear Lake schools. During her career Miles has presented educational courses and been published in several publications that serve the rehabilitation professions. For more information, contact RehabEditor@medqor.com.
- Paleg G, Smith B, Glickman L. Systematic review and evidence-based clinical recommendations for dosing of pediatric supported standing programs. Pediatr Phys Ther. 2013;25:232-247.
- Rivi E, Filippi M, Fornasari E, Mascia M, Ferrari A, Costi S. Effectiveness of standing frame on constipation in children with cerebral palsy: a single subject design. Occup Ther Int. 2014;115-1.
- Nordstrom B, Nyberg L, Ekenberg L, Naslund A. Psychosocial impact on standing devices. Disabil and Rehab Assist Tech. 2013;1-8.
- Hagglund G, Andersson S, Duppe H, et al. Prevention of dislocation of the hip in children with cerebral palsy: The first ten years of a population-based prevention programme. J Bone Joint Surg, Brit Vol. 2005;87-B(1):95-101.
- Ruzbarky JJ, Beck NA, Baldwin KD, Sankar WN, Flynn JM, Spiegel DA. Risk factors and complications in hip reconstruction for nonambulatory patients with cerebral palsy. J Child Orthop. 2013;Dec 7(6):487-500.