Evidence Update: Shining a Spotlight on Supported Standing for Children and Young Adults with Non-Ambulatory CP

For children with non-ambulatory cerebral palsy, supported standing has long been recognized as a beneficial intervention. Research to date shows that supported standing positively impacts hip stability, bone mineral density, range of motion, participation, and overall quality of life. Therefore, adaptive standing is a pillar of early intervention, postural management, and physical activity for this population.

For children who use wheel mobility, supported standing addresses fitness, function and friendships by providing an alternative upright position that relieves the pressure of prolonged sitting, helps with management of contractures and bone health and, most importantly, allows the child to interact with his peers at eye level. .

Although the clear benefits of standing for children with significant levels of disability are recognised, there are gaps in the evidence to adequately inform intervention. For this reason, McLean, Paleg and Livingstone conducted a comprehensive synthesis of the available evidence on the situation to provide recommendations for clinical practice and future research. The study, “Supported standing interventions for children and young adults with non-ambulatory cerebral palsy: a scoping review” describes the evidence, outcomes, and lived experience of adaptive standing interventions in a population of children and young adults with cerebral palsy. Study participants had GMFCS levels IV and V and were 25 years old or younger. The study findings were summarized into body functions and structures and activity outcomes, complementary considerations, and lived experience of supported standing.

Supported position results

Body functions and structures and activity.

Because children with non-ambulatory cerebral palsy are particularly predisposed to decreased bone mineral density and osteoporosis as they grow, researchers say that supported standing is worth it to increase bone mineral density, prevent fractures, and subsequent disability. This intervention is particularly impactful when integrated into a child’s daily routine to improve function and participation.

Evidence also supports the use of adaptive supports to maintain postural alignment and prevent contractures. This not only reduces pain and deformity associated with asymmetries, but also helps the child maintain the movement necessary to actively assist in sit-to-stand transitions that allow for the benefits of weight-bearing and active use of muscles. This purpose is more important than we might assume, especially because it can contribute to independence in activities of daily living throughout an individual’s life. For this reason, the researchers conclude that adaptive positioning is an important part of 24-hour positioning initiatives that may further contribute to reducing spasticity and benefit other functions of daily living.

Several studies have also examined the benefits of standing with abduction support in maintaining hip integrity in children with GMFCS levels IV and V. This is because in the growing child, weight bearing and physical activity contribute importantly to hip alignment and stability. Although the evidence remains inconclusive, researchers note that clinical practice is consistent with 10 to 15 degrees of abduction per side for at least 1 hour every day to reduce hip migration. Trends in the literature suggest that supported abduction positioning should continue throughout the developmental years for greatest benefit.

Additional considerations for the supported position

Choosing the appropriate type of standing (prone, supine, or mobile) to meet the child’s particular goals is important when designing standing programs. For example, if improving bone mineral density is a priority, research can guide us on the type, alignment, and features of support for best results.

Supported standing interventions additionally address sedentary behaviors in this population. Although guidelines suggest daily doses of moderate to vigorous aerobic physical activity for people with disabilities to maintain their health, this is mostly not feasible for children with non-ambulatory cerebral palsy. However, adaptive standing is an appropriate intervention that helps break sedentary positions throughout the day to increase energy expenditure and promote muscle activity. That’s why we try to replace passive positioning with active sit-to-stand transitions and standing activities in daily routines.

The use of supports in early childhood is another area of ​​intervention. Early childhood is a crucial stage of physical development and most children begin to stand between 8 and 11 months. The researchers note that this is the age at which differences in muscle growth become evident between children with cerebral palsy and those with typical development. Measures such as the Hammersmith Infant Neurological Examination (HINE) also provide an early clinical indication that infants with cerebral palsy may fail to walk independently. Providing comparative developmental experiences in standing and weight bearing has the potential to maximize these key moments of physical development.

Regarding the adaptive standing dose for children with cerebral palsy GMFCS levels IV and V, the literature informs us that it is generally tolerated for 30 to 60 minutes, 5 to 7 times per week. Sixty minutes of standing may be best for treating contractures, while longer periods of 60 to 120 minutes may have a greater impact on bone mineral density and hip stability.

Lived experience of standing with support

The perspectives of children who actually use the standing devices are important in determining the effectiveness of the intervention along with the available evidence. Not surprisingly, research shows that parents, children, and therapists strongly believe in the benefits of supported standing and its value beyond weight bearing in improving bowel and bladder control, function respiratory and psychological state. Parents also typically have a good understanding of stander alignment and how to position their child comfortably.

The researchers also indicate the importance of an individualized evaluation to best match the child’s needs with the appropriate device. Stander comfort and alignment are primary considerations, keeping in mind that stander availability, familiarity, and financing can also be major influencing factors.

Importantly, the key is to offer children the ability to choose when and where to stand. Standing is motivating when it is incorporated into the activities that the child wants to do as part of their daily routine. Standing for the sake of standing without any goal in mind quickly loses its appeal. Close teamwork between parents, therapists, school staff, and the child can enable these opportunities at school and home for better outcomes.

Future recommendations

As with most pediatric interventions, more research is needed to substantiate the effectiveness of supported standing on different outcomes. However, by considering available evidence, clinical experience, and the child’s perspective, the researchers paved the way for evidence-based practice regarding supported standing for children with non-ambulatory cerebral palsy, and provide recommendations for creating guidelines. strong clinics in the future. .

Overall, this scoping review provides a welcome and much-needed contribution to supported standing intervention, clearly showing that adaptive standing programs are well tolerated and, if effectively incorporated into daily routines to improve participation, They may contribute to overall physical health in children with cerebral palsy.

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