Most therapists can attest to the fact that treating children requires creativity and flexibility. Using standers to achieve therapy goals is no different.
The options to provide and enhance standing for children with disabilities can differ from those traditionally available for adults. In addition, therapists need to consider a variety of variables that aren't typically applicable to adult patients, including growth, use in a school setting and the unique behavioral needs of children.
The developmental status and progression of a child is also an important consideration. Children with developmental disabilities may have secondary complications such as hip dysplasia, contractures requiring braces, or g-tubes associated with their condition.
Secondary complications impact decisions about optional features to add to a stander, how much support is required from the stander, and how easy it is to access the child's body for care (for example, the g-tube). The stander must also be able to accommodate any bracing, orthopedic limitation or contracture.
Children with disabilities also have a wide variety of caregivers: parents, grandparents and great-grandparents, school aides, teachers, in-home nurses and nursing assistants.
When many caregivers are involved, it's important that the features of the stander are easily set to their appropriate position and that it's easy to communicate those settings to others. In some cases, the family has to become highly trained so they're able to transfer that knowledge and skill to a caregiver at school.
Finally, we must always keep in mind that children play and have an undeniable urge to move, even when facing mobility challenges.
There are two main classes of standers: stationary and mobile or dynamic. Because mobile and dynamic standers are more common in pediatrics than in the adult population, this article will focus on that classification.
Why mobility? Many children don't like to stand still, and are innately driven to move themselves about. Thankfully, there are options to help achieve this.
The terms "mobile stander" and "dynamic stander" are often used interchangeably in marketing; however, I like to think of them as distinct.
A mobile stander moves because a parent can push it, or because the child can use self-propulsion (with their arms) or power propulsion adaptations to move it.
By contrast, a dynamic stander enables the child to be dynamic or move his own body-for example, to move the legs or weight shift at the trunk.
Mobile standers enable a child to wheel themselves using their arms. Being able to self-determine and execute movement is more than just a convenience; it is an essential part of visual-motor development and may enhance hand-eye coordination and the ability to negotiate movement through space. A self-propelled design is probably the most familiar to therapists.
These are the features that I pay close attention to when prescribing mobile standers for children: how much or how little support is given to the trunk and legs, how easy it is for a parent to use and how easy it is (mechanically) for the child to self-propel.
Additional features to consider include trays or mounting brackets, push handles for parents, and other positions such as prone or supine tilt. I also look to see how well I can support the body and whether you can customize support for a child who is asymmetric or has contractures. Each of these features needs to be matched specifically to the patient's needs, physical capacity and caregiver support.
Nicolas (age 8) shares a hug with his great grandmother.
Of all the variables to consider, I pay close attention to ease of use. Some devices may be easy for me to operate, but difficult for a parent or a grandparent. I make sure parents can easily become independent in using the stander and are comfortable teaching others such as school aides, other family members and in-home nurses. The mechanical efficiency of the self-propelling mechanism needs to be tested out for each child. There is not one best product in this regard; the child and his caregivers need to test each model to determine success of use.
In one popular device, the user is supported in standing and children can wheel themselves. It has an anteriorly placed trunk support with straps to support the legs, pelvis and trunk. The body is positioned at a slight forward tilt and users reach down to their side to propel themselves.
While it is simple to use, it is not ideal if a patient needs a lot of mechanical support to stand or has significant tone or an asymmetric presentation. It is easy to transport this stander and easy for a variety of patients to propel.
I have found that both caregivers and patients find its design and use very intuitive. For example, I trialed this stander with a young child who has spina bifida and as soon as I released the brakes, she was off and moving for the first time under her own power. She maneuvered herself over to the toy shelf in our therapy gym, then turned around to get our attention and pointed at a toy, initiating communication. Without any instruction, she skillfully backed herself up, turned on a dime and decided it was time to go as she headed for the door. It was a true breakthrough for her independence, motor planning and communication.
Newer Options and Designs
Another stander design features contoured pelvic and leg supports for patients who need more support or who have more specific alignment needs. Its brake is very easy to operate with one hand, and the angle of forward tilt is adjustable. This feature can accommodate patients with various ability levels and endurance.
I have used this particular device with patients who need more support to maintain an upright position. For example, I currently have a patient who is two-and-a-half years old without the ability to stand or sit. Due to weakness and low tone, she needs more support for her knees, hips and trunk to stand. The variable tilt will be useful, as this child fatigues easily and cannot yet propel herself independently.
A newer stander on the market has knee pads and support for the hips, pelvis and head. It has variable positioning of foot plates and knee pads for an asymmetric child. I like the control and precision of positioning, but I feel the mobile attachment may be difficult to propel for children who may have compromised arm strength. It does provide a great deal of support and control of the trunk and leg positions.
This stander offers flexibility to position the child in best alignment and the settings are easy to replicate. One of the benefits of this mobile stander is the ability to operate in the sit-to-stand or the supine-tilt operation. It has a variable support and a child can easily grow in this device. As the musculoskeletal needs of the child changes, the support can be changed. For example, if the patient has a contracture, it can be accommodated and even progressively treated by using the knee and foot plate attachments. Asymmetries and even leg-length discrepancies can be accommodated.
I have prescribed this product (without the mobile unit) for a young child with cerebral palsy who has dystonic movements, many contractures, leg and trunk braces, a g-tube and tracheostomy. He benefits from the many options, such as the tray, the harness and the trunk and head supports.
Due to his contractures and movement disorder, this patient requires significant support for aligning his legs and pelvis. He has many caregivers, so the ease in setting the seat depth and back height using the color coding is invaluable.
Once the positioning settings are set, they do not need to be adjusted every time he gets in and out of it, so that benefits his family and in-home caregivers. He can also sit or stand in it and it can be tilted back. He will use the supine tilt feature to provide support and good positioning for his g-tube feeding, and it's easy for caregivers to access the g-tube. He can also use the tilt option to recline for other self-care related to his tracheostomy.
Some standers on the market are power-driven options that can be operated with a joystick or other interface. Some therapists may feel that children who are primarily power wheelchair users do not need another power mobility device. I feel that the opportunity to stand supported while moving about is important, in both the school setting and in the home.
While this option is not limited to children classified as GMFCS (Gross Motor Function Level Classification System) Level IV or V, a power driven stander may be ideal for kids with limited arm motion, since the drive mechanism can be mounted on a tray in front of the child in the best location for the child to operate it.
The tray can provide support to the entire arm and the drive mechanism could be placed in the child's best field of vision. This may be easier for a child to use, compared to a similar drive mechanism that might be attached to the arm of a wheelchair. The ability to stand and move changes the social interactions and learning opportunities possible for a patient, as they can literally be eye-to-eye with their peers.
Dynamic standers include those in which the base or components move in some fashion. In dynamic standers, the child's body moves while the device itself is typically not mobile.
This type of stander can be used to help a patient develop balance and to perform exercises to challenge themselves by reaching outside of their base of support in the upright position. Dynamic standers are great for children to participate in age-appropriate play that would be otherwise impossible while standing, such as tossing and catching a ball.
I now consider another variable with standers that I had not considered 10 years ago: how well can a child play a video game while in the stander? I pay attention to how open the space in front of the torso is, as many children agree to stand longer if they can play their favorite video games. Many of these games rely on full movement of the arms to play.
With that said, the patient has to have good upper-trunk strength with good postural control. I have not personally prescribed one of these for a child to use at home, but since the PT department at Kennedy Krieger Institute has a Wii system, I can see how this stander might be used creatively in the clinic setting with similar video games.
Another dynamic stander on the market is like a cross country ski-machine, in that movement of the arms is coordinated, producing movements of the legs. In addition to the well-established benefits of standing, a child can benefit from the reciprocal activity of the arms plus the legs. There is evidence that this type of reciprocal movement elicits EMG activity in the leg muscles and can help regulate the vital response to being upright through effective muscle contraction and appropriate cardiovascular challenge. Even if a child is not fully able to move his arms, a caregiver can push the arm handles and produce a full range stretch throughout the legs into hip extension.
When prescribing this type of stander, make sure the child has sufficient joint range of motion and joint integrity, and modify its use based on the patient.
Ease of transfer is another variable to consider in pediatrics. It's not uncommon for grandparents to provide care, so take into consideration the caregiver's physical capacity.
With creativity and flexibility, physical therapists have an arsenal of standing options available to them and their patients. The therapeutic benefits are numerous and we must remember that standers can benefit those children whose immediate goals may not include standing or walking independently. The benefits for those children are, perhaps, even greater because they involve deep emotional and social rewards.
It's empowering for patients to be able to move around independently or move in a way they haven't before. They can look into their parents' eyes and smile, hug their grandparents and realize they're actually taller than their friends.
For me, this is as rewarding an outcome as improvements in trunk control or postural alignment. I encourage other physical therapists to do some research to find the best stander to achieve the same outcome for their patients.
Karen Good is a senior physical therapist at the Kennedy Krieger Institute in Baltimore.