Pediatric special needs patients combat the exhausting effects of gravity on a daily basis. Low muscle tone, muscle contractures, skeletal deformities, orthopedic issues, and poor circulation are just a few of the dysfunctions these young clients face. For children unable to independently support their bodies against gravity, extended time spent sitting in wheelchairs and other adaptive options are a painful daily reality.
Two northern Kentucky pediatric specialists understand the effects children face when their joints are rarely opened up to a standing position. Jennifer Clause, PT, of Boone County Schools, and Amy J. Martin, PT, owner of Pediatric Therapy Specialists Inc., a small pediatric practice offering PT, OT and speech services, know how pediatric standers have positively impacted functional outcomes with their clients.
Variety of Indications
Among the 12% of their patients who are currently using pediatric standers, both therapists report a wide variety of diagnoses. Limited function secondary to cerebral palsy, brain injury, multiple organ failure, undiagnosed low muscle tone, and shaken baby syndrome have all been noted by the therapists to benefit.
"A stander is an appropriate tool for kids who are unable to stand with less support. The physical therapy goal of using a stander may be to increase strength and endurance. For some kids, it may be a temporary strategy to work toward independent standing and eventually walking," shared Martin. "Other kids may need to use a stander long term. This can be a wonderful way to provide a stimulating and functional experience where caregivers can have their hands free to interact with the child, rather than trying to hold them upright themselves. A stander provides a good opportunity to try switches to aid communication or to activate toys or other adapted equipment.
Physical and Emotional Benefits
According to Clause, physical and emotional benefits are numerous. "I've seen improved head and neck control, as well as heel cord and hamstring lengthening, which positively affects their ability to stand outside of the device. Other benefits include a decreased incidence of hip flexion contractures, as well as a slowed progression of scoliosis," she said. "A stander increases the child's potential to ambulate and take at least a few steps, which can decrease the burden of the caregiver in helping them with transfers as they get older."
Other benefits include enhanced digestion, respiration and bone density. Sensory input from being in a safely supported standing position prepares the child for future ambulation. If already ambulatory, proper joint alignment in prolonged standing postures may reduce the risk of secondary physical deformities.
In addition to their older pediatric case-loads, which include children through middle school age, Clause and Martin work with much younger patients through First Steps, a statewide early intervention system that provides comprehensive services to clients with developmental disabilities from birth to age three.
"I am currently working with a two-year-old client who has shown improved ability to bear weight through her legs in a supported standing position with her family gently holding her," Martin said. "[It] began when she started using a stander consistently at the child care center about four weeks ago. It is supported in the literature and generally understood that weightbearing in this way promotes improved circulation and stronger, better developed bones - specifically the acetabulum. Standing stretches and engages soft tissues in a more typical way. The position also allows peers to be face-to-face and to observe their physical environment from a different perspective."
Clause concurs that face-to-face positioning is one of her favorite personal benefits of standers. "Standers put the child at eye level with their peers, and they are so much more approachable for other kids to interact with them in class as well as at home," she said. "This is a huge psychological benefit that adds to their feeling of wellness. Plus, it lets the other kids see that these kids need 'just need a little help' walking, and they are like them in a lot of ways. This is a huge advantage in a school environment."
Options on the Market
Therapists have many options of pediatric standers suited to client needs. Supine standers tilt the child slightly backward, providing support along the posterior surface of the body. Supine standers are a good choice for children with lower muscle tone, trunk and head control, and limited standing experience.
Courtesy Photographer Wayne Clause of Phrozen Fotos.
Prone standers provide support along the anterior surface of a child's body and incline the client slightly forward. Because of this added gravitational challenge, they necessitate at least emerging control of the head and trunk.
For clients who can transfer in sitting, a stander with a seat providing a mechanism for sit-to-stand is a nice feature. Additionally, dynamic standers with wheels offer easier maneuverability for caregivers. Dynamic standers can also be fitted with larger-rimmed wheels so highly functioning patients can self-propel.
"I prefer supine standers for younger pediatric or very low-tone clients, but for older and stronger clients, I think a sit-to-stand type is preferable because it is sometimes easier to get them into it," Martin said. "Several standers have supine and prone capabilities in one, and it is nice to have that versatility."
Clause stresses the ease of use with a sit-to-stand model, especially with bigger kids. "It really depends on the needs of the child, and if they are able to propel the stander on their own," she related. "If so, then a dynamic prone stander is an excellent option."
Courtesy Photographer Wayne Clause of Phrozen Fotos.
"Adjustability for the caregiver and comfort for the user is at the top of my list," Martin said of the qualities that make a good stander from a clinician's standpoint. "It is also important that the stander is easy to move around in the room."
"The ability for a single person to get the child in the stander is also a big factor," added Clause. "Another consideration is storage. Where can the family place the stander when not in use?"
Positioning and Duration
All standers are equipped with positioning stabilizers, which vary with stander type. Selection depends on the client's functional abilities, personal needs, comfort, and goals. Bands and solid blocks for the trunk, pelvis, hips, knees and feet, along with head supports and trays, are available so the therapist can design a safe, progressive weightbearing program for each child.
Martin and Clause state that the duration of stander sessions is dependent on patient comfort. Beginning with 30 minutes a day usually works well, building up to an hour as tolerated.
"If the stander is a dynamic model and can be moved easily by the caregiver or patient, then standing time might be increased to two hours per day," said Clause.
School-aged patients who use a stander in the classroom often find it helpful to have one at home as well. Many families will pursue private pay options, finding that their insurance may cover a stander if medically necessary. If a stander is able to be independently secured, then families might elect to leave it at school during the school year, and take it home for the holiday and summer vacations.
Client and Family Response
When asked whether her patients enjoy their sessions in the standers, Clause shares that most do, though it takes some children more time to get used to it than others. "For these kids, especially the really young ones, we have to use some distractions like music and toys to get them to tolerate it," she said. "Most families are also excited to use them, but there are some that are very intimidated by the standers. I may need to repeatedly demonstrate the technique for these families and provide some written instructions."
"I had a family that just didn't want their home to look like a therapy clinic so they weren't ready to have it in their home," added Clause. "In cases like these, I simply try to accentuate the benefits to the child so that they don't think it is just 'one more thing' they have to have in their home to take care of their special needs child. I really try to emphasize that it is particularly important to provide standing opportunities as their child grows, especially if they are not able to weight bear on their own."
"The standing experience is a very individualized thing," summarized Martin. "Some kids will immediately enjoy the experience, while others will need to take it slow to build endurance. I do believe that families and teachers enjoy seeing their children able to engage in experiences that have significant benefits, both physically and socially."
Robin Bradley Hansel is owner of Green Treehouse Media LLC and Labyrinth Wellness LLC, both located in South Florida.