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Recent updates to clinical recommendations on the use of hip abduction in standing frames highlight the need for individualised, and child-centred, approaches to standing frame prescription.
Background
Hip displacement (HD) is the second most common musculoskeletal deformity in children with CP[1]. HD has been found to be directly correlated to the Gross Motor Function Classification System (GMFCS). The children who cannot mobilise independently, classified as being level III-V on the GMFCS, are at a significantly greater risk of developing hip displacement compared to those who walk independently at levels I or II [2]. HD affects over one-third of children with CP, and the incidence of HD may be as high as 90% in those functioning at GMFCS level V. The risk of displacement is highest between the ages of 2-5 years in children with CP, when the infant hip joint is in rapid development [3].
HD can cause significant pain and disability, and if untreated, may develop into full hip dislocation and cause postural and gait abnormalities, scoliosis, hip joint pain and problems with perineal hygiene [4,5]. Furthermore, management of HD can often involve painful and invasive surgical procedures such as soft tissue lengthening of spastic muscles, guided growth of the proximal femur, femoral or pelvic osteotomies and salvage procedures [6].
Therefore, it is paramount that conservative therapeutic approaches which can aid the management of HD in CP are identified to guide clinical practice.
Abnormal muscle and joint contact forces in CP may lead to the development of bone deformities such as increased femoral neck angle and neck-shaft angle (which are normally decreased in typical development) and an acetabulum which isn’t as round and deep and therefore doesn’t fully support the head of femur (see Fig.1.).
Fig. 1
With these factors in mind, conservative approaches often try to maintain well – located hips through stable and symmetrical positioning. In recent years, abducted standing has grown in popularity. The aim of abducted positioning in a standing frame is to place the femoral head more centrally within the hip joint, overcoming the atypical proximal femoral geometry in a CP hip to help aid acetabular development (see Fig. 2). Other aims include reducing spasticity and maintaining hip range of motion through stretching of the hip adductors and hamstrings.
Fig. 2.
Two heavily cited studies from Martinsson and Himmelmann have suggested that regular supported standing with hips abducted between 15 to 30 degrees each side can reduce HD trajectory, with the most beneficial outcomes seen in those who stood maximally in hip abduction (60 degrees bilaterally) for 10 hours per week, and even more so in those who stood in this way after soft tissue lengthening surgery [7,8]. This was compared to control groups who stood in neutral to 10 degrees. A systematic review in 2013 with clinical recommendations also suggested that standing daily in 60 degrees of total bilateral hip abduction may improve hip biomechanics [9].
Updated recommendations
More contemporary thinking has built upon this evidence base, evaluating the quality of research and providing recommendations with more child-centred thinking.
Both the Norwegian Quality and Surveillance Registry for Cerebral Palsy’s (NorCP) ‘Evidence-based Guideline for Diagnosing and Follow-up of People with Cerebral Palsy’ and two scoping reviews from some of the authors of the 2013 systematic review have suggested smaller amounts of hip abduction in standing, between 10 to 20 degrees per leg, for up to one hour per day [10,11,12].
Children with CP are often affected by spasticity, limited range of movement and contractures in muscles like their hip adductors. Being able to stand with hips abducted to 30 degrees each leg is one thing, but being comfortable, happy and pain free in this position is another. Try stand in maximal hip abduction yourself – how comfortable do you feel?
Standing for one hour per day, five days per week, compared to the 10 hours suggested in Martinsson and Himmelson’s studies, is also a more realistic recommendation accounting for typical everyday home and school life.
Furthermore, the NorCP guideline emphasised their recommendations more so for children under the age of 5 – relating to those ages where there is the highest risk of hip displacement.
It is worth noting the evidence supporting abducted standing approaches is limited by the small number of trials conducted, and methodological quality issues with these trials such as small sample sizes in the experimental groups and the potential for high variability in the standing programmes of the comparator groups. The scoping review from 2023 points out that hip abduction alone does not necessarily ensure correct placement of the femoral head [11]. Factoring in the child’s postural presentation and tone, we may need to consider hip extension, external or internal rotation adjustments.
However, despite the limited evidence, it stands to reason that non-conservative therapy approaches should be applied where possible if the potential benefit will outweigh any risks. For example, use of hip abduction in standing can still be a positive approach after 5 years of age if the child continues to have a risk of increasing hip migration, if we want to gently stretch spastic musculature, post surgery, and most importantly, if the child is happy and engaged in their standing frame.
When applying evidence-based research into practice, we need to balance it with the child’s individuality and everyday life in mind.
[1] Howard, J. J., Willoughby, K., Thomason, P., Shore, B. J., Graham, K., & Rutz, E. (2023). Hip Surveillance and Management of Hip Displacement in Children with Cerebral Palsy: Clinical and Ethical Dilemmas. Journal of Clinical Medicine, 12(4), 1651. https://doi.org/10.3390/jcm12041651.
[2] Soo, B., Howard, J.J., Boyd, R.N., Reid, S.M., Lanigan, A., Wolfe, R., Reddihough, D. & Graham, H.K. (2006) Hip displacement in cerebral palsy. J Bone Joint Surg , 88(1), 121–129. DOI: 10.2106/JBJS.E.00071.
[3] Malone, A., Tanner, G. & French, H.P. (2025) Longitudinal relationship between hip displacement and hip function in children and adolescents with cerebral palsy: A scoping review. Dev Med Child Neurol. Apr;67(4):450-462.
[4] Wawrzuta, J., Willoughby K.L., Molesworth, C., Ang, S.G., Shore, B.J., Thomason P. & Graham H.K. (2016). Hip health at skeletal maturity: A population-based study of young adults with cerebral palsy. Developmental Medicine and Child Neurology, 58(12), 1273–1280. https://doi.org/10.1111/dmcn.13171.
[5] Aroojis A., Mantri N. & Johari, A.N. (2020). Hip Displacement in Cerebral Palsy: The Role of Surveillance. Indian J Orthop, 55(1):5-19. doi: 10.1007/s43465-020-00162-y.
[6] Judd H, Hyman JE. Operative treatment of the young cerebral palsy hip. J Pediatr Rehabil Med, 15 (1):13-17. DOI: 10.3233/PRM-220022.
[7] Martinsson, C. & Himmelmann, K. (2011). Effect of weight-bearing in abduction and extension on hip stability in children with cerebral palsy. Pediatr Phys Ther, 23(2):150–157. DOI: 10.1097/PEP.0b013e318218efc3
[8] Martinsson, C. & Himmelmann, K. (2021). Abducted Standing in Children With Cerebral Palsy: Effects on Hip Development After 7 Years. Pediatr Phys Ther,33(2):101-107. DOI: 10.1097/PEP.0000000000000789
[9] Paleg, G.S., Smith, B.A. & Glickman, L.B. (2013).Systematic review and evidence-based clinical recommendations for dosing of pediatric supported standing programs. Pediatr Phys Ther, 25(3):232-47.
[10] NorCP. Cerebral Palsy. Retrieved 15/12/2025 from: https://metodebok.no/bok/cerebralparese/cerebral-parese-(norcp)
[11] McLean, L.J., Paleg, G.S. & Livingstone RW. (2023). Supported-standing interventions for children and young adults with non-ambulant cerebral palsy: A scoping review. Dev Med Child Neurol, 65(6):754-772. DOI: 10.1111/dmcn.15435
[12] Paleg, G. S., Williams, S. A., & Livingstone, R. W. (2024). Supported Standing and Supported Stepping Devices for Children with Non-Ambulant Cerebral Palsy: An Interdependence and F-Words Focus. International Journal of Environmental Research and Public Health, 21(6), 669. DOI: 10.3390/ijerph21060669.
