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Formulating Proper Dosage for Standing

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A program model that provides standing opportunities at all ages enhances development while facilitating greater activity, quality of life, and independence.

  

by Melissa K. Tally, PT, MPT, ATP, and Erin M. Pope, PT, MPT

The use of a standing device can enhance and facilitate the ability and development of persons with physical disabilities to be more productive and self-reliant within their home, school, and community environments. We have the unique opportunity to work in a center providing holistic multidisciplinary therapy intervention and assistive technology for pediatric and adult populations. It is our standard practice to implement a standing protocol in the Plan of Care for all appropriate individuals participating in our therapeutic programs and assistive technology evaluations.

Clinicians must rely on all available resources to aid in proper formulation of dosage, including clinical experience and expert opinion. Current literature on dosage is limited, even on well established medical benefits of standing. Outcomes cannot be fully supported by evidence, and the dosing information that is provided is often inconsistent. It is essential to have a thorough grasp on each unique patient and that individual’s needs to determine the best stander prescription and dosage. Evaluation for a standing device should be performed, as a set standard of practice,1 by the evaluation team consisting of an occupational or physical therapist, a certified ATP equipment vendor, the family, and the patient.

Categories of Standers

The results of the evaluation will guide the clinician toward the most appropriate standing system. Categories to consider include supine, prone, multi-positional, and mobile standers. A supine system may be necessary to provide a more supportive and optimal resting position for the head and trunk during standing, while a prone device will provide the opportunity to utilize existing head and trunk strength. Multi-positional standing systems are useful for patients who are continuing to build tolerance to standing, have significant range of motion limitations, or for those who want to limit transfers. Mobile standers, defined for this purpose as a stander with wheels to roll around, offer yet another option by providing a means for exploration of the environment, and are highly beneficial for pediatric clients or adults in a work environment. Once a decision is made regarding the type of system required, with adherence to the above guidelines and input from the evaluation team, the specific product will often reveal itself.

Benefits and Dosage

 

Research about standing devices has repeatedly established that they are therapeutically effective as treatment for certain physical impairments associated with a variety of neuromuscular conditions.2 It is important to note that some of these benefits are being disregarded or questioned, which has had a significant impact on funding. Standing systems are often prescribed to control and/or treat a variety of secondary complications. The most documented dosage at this time relates to musculoskeletal benefits, including bone mineral density,2-4 range of motion,2,5-9 and spasticity.2,8-10 Regular adherence to a standing protocol of 45 minutes to 60 minutes daily has been shown to improve range of motion and spasticity, with 60 minutes to 90 minutes to improve bone mineral density.2

 

It is our clinical opinion that the intended benefits of the standing system correlate with the expected dosage. Formulating proper dosage for stander use consists of several key components: type of stander recommended, frequency and duration of expected use, environment where it is to be used, positioning within the standing device, and functional activity to be performed. This formula is applied with every patient recommended for a standing device.

 

The multidisciplinary therapeutic environment in which we treat our patients has allowed us to implement a standing protocol across the lifespan. We have applied evidence-based practice as well as practice-based evidence into this model of care. Our standing protocol is divided into categories of developmental transitions, each of which has specific outcomes impacting the recommended dosage of their daily standing program.

 

A Standing Program Model

 

Birth to age 3 years: It is well known that typically developing children begin crawling and pulling to stand at age 7 months to 9 months. This skill is crucial for early exploration and cognitive development.11,12 While the musculoskeletal effects of the child with cerebral palsy or related disorders are not as apparent during this period, the need for cognitive enrichment and learning remains essential.

 

With appropriate supports and positioning, adapted standing allows play and learning. Devices available to this age group are limited, but do exist. Many commercial products that target typical 6-month to 12-month-old children will work with therapeutic modifications. Examples include long leg splints, bracing, Hensinger collar, etc. Several manufacturers have developed products targeting early intervention and preschool age, and products are available to support a child as young as 7 months to 10 months.

 

The trick at this age is determining whether the child’s disabilities will require an ongoing need for adaptive equipment, and a stander should be prescribed instead of a short-term loan during an interim of development. It is at this point that the therapist’s clinical experience and presenting abilities of the child come into play. Other considerations should include the child’s need for active mobility—perhaps a gait trainer may be a more appropriate choice at this time, for both the patient and his family.

 

Families are overwhelmed during this period, coping with the diagnosis of their child and what this means to them now and in the future. Often, providing a means for their child to meet the milestone of “standing” offers a critical period of development for the child, as well as a point of healing for the family.

 

Therapeutic dosage of standing at this point in the lifespan relies more on the child’s tolerance and endurance and the caregiver’s ability to incorporate standing into their daily routines. Standing with the child from birth to age 3 years is initiated with a standing program of 5 minutes to 10 minutes, 2 times to 3 times per day, with a plan to increase tolerance to 45 minutes to 60 minutes at least once daily.

 

Preschool: For the preschool-aged child, the critical focus continues to be standing and mobility. Balancing the need for static standing as well as opportunities for dynamic movement continues to be a struggle in terms of equipment recommendations. Typical preschoolers are up and moving constantly, learning about their environment and developing crucial fine and gross motor skills. Their minds and bodies grow at a rapid pace. With this growth comes increased concern and awareness of secondary complications for our patients. Hip integrity and development13,14 and equipment tolerance are significant outcomes to consider, as well as the need for improved access to assistive technology and learning.

 

The child now enters the world of preschool enrichment, allowing further opportunities for upright positioning and peer interaction. The therapist, family, and teacher need to look at the daily routine to

determine where standing can be incorporated. This new environment should not remove the need for standing at home, but offer opportunities to increase standing dosage.

 

Our standing program recommends a minimum of 60 minutes to 90 minutes of standing per day. At this age, the ability to stand in a gait trainer with the wheels locked or free for dynamic mobility may be considered in the treatment plan. Families and teachers are very busy and this must be a consideration. It is our experience that compliance of caregivers increases if they are provided the optimal equipment for the child and the environment and if standing dosage is incorporated into daily activities or meaningful tasks.

 

School-Age: As the child ages, more of the day is spent in the school setting. This leads to more time spent in a seated position if not provided opportunities to stand. On the other hand, increased time at school allows more time to work standing into a functional, daily routine. This commonly is a time when families forget or discount the standing program recommended for their child; however, several transitions of development and growth occur during this time and standing should remain an essential part of treatment. The primary outcomes of standing at this age are to target the secondary complications associated with growth spurts. It is typically during this time that a child outgrows the original standing frame or needs to add a standing frame to the plan of care.

 

School also provides the opportunity to incorporate 60 minutes to 90 minutes of standing into a child’s day, if the school team and therapists have the appropriate equipment and work together to incorporate standing without disrupting learning. Our experience is not in the classrooms of the children we serve,

but in years of collaboration with families and school teams. It is recommended to have a stander both at school and at home. The standing frame and dosage recommended for a child in the school setting may not be the same recommended for home. While the stander at home should be specific to the child, home, and caregiver’s ability to transfer, the stander at school may be more universal to accommodate multiple students throughout the day. At this age, it is recommended children continue standing frequently throughout the day; 45 minutes to 60 minutes at school (at least once per day) and then again at home for the same duration to attain the recommended dosage.

 

Young Adult/Adult: The ongoing use of standing frames and the dosing of standing protocols must continue into the aging disabled population. While factors associated with growth, outside of weight management, are decreased, the need to combat secondary complications and allow participation remains. Compliance with a daily standing protocol can aid in the health, maintenance, and well-being of a patient and that individual’s family.10 The dosage for standing remains similar, but the adult may need to incorporate standing for work-related tasks, recreation, pain management, or socialization. Standing functions may be incorporated into power mobility. Funding of standers for this age group is often challenging, but alternative funding should always be discussed.

 

Providing standing opportunities at all ages enhances overall development while facilitating greater activity, participation, quality of life, and independence. Standing enables our patients to be in an age-appropriate position, up with their peers, further enhancing cognitive and social development. Standing frame selection and appropriate dosage must include considerations for specific environmental and personal factors16 including age, function, and caregiver abilities. It is essential that persons with cerebral palsy and related conditions are able to access such devices as part of their care, treatment, and rehabilitation across the lifespan. RM

 

Melissa K. Tally, PT, MPT, ATP, and Erin M. Pope, PT, MPT, work for the Perlman Center at Cincinnati Children’s Hospital and Medical Center. The center is part of the Cincinnati Children’s Hospital CP program. For more information, contact cincinnatichildrens.org/Perlman.

 

 References

 

1. RESNA Code of Ethics and Standards of Practice.  RESNA.org; http://resna.org/certification/ethics-and-governance.dot. Accessed March 12, 2012.

 

2. Glickman LB, Geigle PR, Paleg GS. A systematic review of supported standing programs. J Pediatr Rehabil Med. 2010;3(3):197-213.

 

3. Stuberg W. Considerations related to weight-bearing programs in children with developmental disabilities. Phys Ther. 1992;72(1):35-40.

 

4. Paleg G. Standing strong. Advance for Physical Therapists and PT Assistants. 2005;16(9):39.

 

5. Tremblay F, Malouin F, Richards CL, Dumas F. Effects of prolonged muscle stretch on reflex and voluntary muscle activations in children with spastic cerebral palsy. Scand J Rehabil Med. 1990;22(4):171-80.

 

6. Gibson SK, Sprod JA, Maher CA. The use of standing frames for contracture management for nonmobile children with cerebral palsy. Int J Rehabil Res. 2009;32(4):316-23.

 

7. Bohannon R, Larkin P. Passive ankle dorsiflexion increases in patients after a regimen of tilt table-wedge board standing. Phys Ther. 1985;65:1676-1678.

 

8. Baker K, Cassidy E, Rone-Adams S. Therapeutic standing for people with multiple sclerosis. Int J Ther Rehabil. 2007;14(3):104-109.

 

9. Salem Y, Lovelace-Chandler V, Zabel RJ, McMillan AG. Effects of prolonged standing on gait in children with cerebral palsy. Phys Occup Ther Pediatr. 2010;30(1):54-65.

 

10. Eng JJ, Levins SM, Townson AF, Mah-Jones D, Bremner J, Huston G. Use of prolonged standing for individuals with spinal cord injuries. Phys Ther. 2001;81(8):1392-9.

 

11. Kermoian R, Campos JJ. Locomotor experience: a facilitator of spatial cognitive development. Child Dev. 1988;59(4):908-17.

 

12. Savelsburgh GJP, ed. The Development of Coordination in Infancy. Amsterdam, The Netherlands: Elsevier Science Publishers; 1993.

 

13. Gudjonsdottir B, Mercer VS. Hip and spine in children with cerebral palsy: musculoskeletal development and clinical implications. Pediatr Phys Ther. 1997;4:179-185.

 

14. Pountney T, Mandy A, Green E, Gard P. Management of hip dislocation with postural management. Child Care Health Dev. 2002;28(2):179-85.

 

15. Hägglund G, Andersson S, Düppe H, Lauge-Pedersen H, Nordmark E, Westbom L. Prevention of severe contractures might replace multilevel surgery in cerebral palsy: results of a population-based health care programme and new techniques to reduce spasticity. J Pediatr Orthop B. 2005;14(4):269-73.

 

16. International Classification of Functioning, Disability, and Health. http://www.who.int/classifications/icf/en/.  Accessed November 25, 2012.