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Why Stand? 

Standing is so important for every child, and has a wide range of benefits for their health and development. 

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When development is unhindered, children start pulling themselves to a standing posture from as early as nine months old. This naturally progresses to cruising along furniture, then walking with hands held, to independent walking from approximately 12 months old. The ultimate goal is being able to move from one place to another at will, and achieve all the day-to-day play, selfcare and school or work activities that are still to be learned. When development is seamless, we take this progression for granted, and don’t stop to think how important the upright posture is.

However, when children display a delay in their development, through a known cause (such as Cerebral Palsy (CP), Muscular Dystrophy, Spina Bifida, Downs Syndrome etc) or for an unknown reason which prevents them from weight bearing independently, this developmental progression may not take place or skills already gained may be lost. 

Independent standing may not ultimately be achievable. However, children should be given the opportunity to be in a standing position using specially-designed standing frames, so that they can benefit from the many positive effects of standing.

What Is A Standing Frame?

A standing frame is a piece of equipment that can support an individual to maintain a standing position.

They generally consist of a solid frame, normally with wheels at the bottom so the frame can be moved, and then more comfortable pads and straps that support the child in the desired position.

9 Benefits Of Using A Standing Frame

Bone Density

Bone mineral density is a measure of bone strength - high bone density means stronger bones, which are less likely to break.


Normal bone growth and development requires a combination of good nutrition, weight bearing and the use of muscles. However, research has shown that standing for 60-90 minutes, five times per week, has the potential to positively affect bone density1.


During these periods of standing, it is important to ensure that your child is weight-bearing symmetrically. The use of a suitable standing frame, postural supports and straps can help to fully load the legs.

 

Experts also recommend that multiple short bouts, including loading and unloading and sit-to-stand transfers, may also be more valuable than static standing alone.

Cardiovascular Function

Effective circulation is closely related to respiration and breathing, as the efficient supply of oxygen to the blood, followed by the circulation of oxygenated blood around the body is what keeps us healthy. But how is this related to standing?

 

Standing has been found to improve blood pressure, heart rate and to decrease fluid build-up (oedema) in the legs and feet. In fact, it is recommended that 40 minutes of standing, three to four times per week, may reduce leg and foot swelling2.

 

Repeated and progressive standing may improve functional circulation, but it is advised to cease standing activity if vital signs become unstable - for example, if oxygen saturation levels fall below 90%

Digestion and Toileting

It is well known that children with additional needs, particularly those with Cerebral Palsy, can often face difficulties with digestion and elimination. Another benefit of the use of standing frames is improved digestion and the management of constipation3.

 

Anatomically, standing is believed to help with digestion and toileting through a combination of gravity and the activation of stomach muscles. Adult studies suggest that the use of a standing frame for 30-60 minutes per day could decrease the use of suppositories. With this in mind, toileting programmes could be incorporated with standing frame sessions to ensure the child has the best possible chance to achieve bladder and bowel control4.

 

You can read more about ways to manage constipation in our recent blog.

 

8 Exercises To Manage Constipation

Respiration and Voice Control

When we stand, the diaphragm has more room to expand and contract, meaning we can breathe in and out more easily, deeply and efficiently.

 

This aids in both volume and voice control.

Skin Integrity

When we sit for extended periods, our sitting bones and sacrum (bottom of back) can become vulnerable to pressure and potential skin breakdown.

 

Standing improves both breathing and circulation so, with this in mind, it seems logical that standing would allow oxygenated blood to more easily reach these areas that are subject to pressure, and give the skin opportunity to repair.

Increased Alertness and Self-Confidence

Did you know that the improved alertness that standing brings can improve concentration and attention-span7?

 

As well as this, being upright, at an equal height to their peers, has the potential to change a child’s view of themselves and how they can interact with the world.

 

This improves their self-awareness and overall self-esteem, and many examples of this have been observed with children in environments such as the classroom.

Hip Joint Integrity

Children who stand at the age of 12-16 months are typically considered more likely to form a more normal ball and socket joint, but children who spend the majority of their time sitting can experience hip problems as they develop.

 

In these cases, supported standing, as one part of a comprehensive hip management program, has been shown to possibly prevent repeated need for hip surgery.

 

It was also noted that standing for children as young as 14 months resulted in improved hip range of movement5.

Reducing Spasticity

Another huge benefit of standing is specific to children diagnosed with Spastic Cerebral Palsy, the most common type of CP, making up 70%-80% of cases.

 

Spasticity refers to an increase in muscle tone, in which the muscle spasms are increased by movement. In these cases, muscles often develop contractures, whereby the movement of the joint is limited, and muscles appear functionally “short”. By stretching the muscles, standing has been noted to reduce the spasticity a child experiences, with reduced tone found to last for 30-45 minutes after a prolonged stretch6.

 

By reducing the spasticity your child experiences, it may help them to utilise their selective control more effectively and functionally. It also has the potential to enable some children to improve weight-bearing and walking efficiency.

Improved Socialisation

One final benefit of standing is improved socialisation7, and better access to a child’s environment. As we mentioned previously, standing frames place children at eye level with their peers, giving them more opportunities for unplanned interaction and socialisation.

 

Another advantage to being upright is enabling them to access previously restricted parts of their environment.

 

Whether actively participating in the classroom at whiteboards or water tables, participating in group activities, or getting more involved in day-to-day life, such as helping parents with the dishes, painting, or playing throw and catch. These are all valuable experiences that will help to shape your child, both mentally and physically.

Types Of Standing Frames

Standing frames are available in three base configurations - although some are designed to transition between all three configurations. These are:

  • Upright standers (with or without dynamic base)
  • Supine standers
  • Prone standers

When it comes to choosing the correct standing frame, you will be guided by your therapist on the correct standing frame for your child and their stage of development.

Regardless of the style of the standing frame, the most important element is the achievement of desirable postural alignment. However, if you would like to know more about these frames and their key differences, the posters below will help you to understand the factors that come into consideration when choosing the correct frame for your child.

Upright Standing Frames

Upright standing frames are designed to support children in a fully upright position so that their head and trunk is balanced over their pelvis.

They can sometimes be called ‘dynamic standing frames’ dependent on what wheels or base they have. For example, there are upright standing frames with large wheels so the user can move themselves around or there are frames that have rocker-type base that enables the user to rock backwards and forwards which, if used under the guidance of a therapist can help develop head and trunk control.

Learn more about Targeted Training in our Squiggles TT Clinical Workbook

Pros

  • Maximum weight-bearing is achieved
  • Enables more active transfers
  • Good for developing postural control

Cons

  • Can be tiring for longer periods
  • Can be harder to accommodate more severe hip and knee contractures

Supine Standing Frames

Supine Standing Frames are those in which a child or young person is lifted or hoisted into a lying position, with the standing frame supporting them from the back. The frame is then brought upwards to a more upright position, depending on ability.

Pros

  • Good for children who struggle with head control
  • Easier for hoist transfers
  • Can accommodate more severe knee and hip contractures

Cons

  • Too much supine tilt can reduce interaction

Prone Standing Frames

In Prone Standing Frames, a child or young person is tilted slightly forward and supported from the front.

Pros

  • Engages trunk and neck muscles against gravity
  • Encourages weight bearing through upper limbs
  • Enables more active transfers

Cons

  • Can be tiring for longer periods
  • Harder to accommodate more severe hip and knee contractures

What Should My Child Do In A Standing Frame?

It is important to keep activities fun and engaging when your child is in a standing frame. This helps them remain active in the frame rather than just taking all the support that the frame gives them.

Each child's preferred activities will be completely personal, based on what they enjoy. Some children love messy activities such as baking or paiting, whilst other might prefer to listen to a story or play with toys whilst in the frame.

Activities will also be dependent on the level of support they need. For example, if your child is working on their head control, activities such as turning their head to choose a toy, or indicate that they want a page turned in a book might be challenging enough; whereas children working on their trunk control might be able to use their hands to pop bubbles or swipe at toys.

Need Some Activity Inspiration?

Ask A Physiotherapist: 5 Common Questions About Standing

Standing is so important for every child, and has a wide range of benefits for their health and development. Conversations around standing typically start in consultation with medical professionals, but many parents or carers find themselves researching the answers to their questions online between appointments. We’ve put together some of the most common questions and answers, to ensure that you can find accurate and relevant information in one place.

  • When should my child start using a standing frame?

    The decision to start using a standing frame is one that you will make with your physiotherapist or another medical professional. However, generally speaking, children who are not pulling-to-stand, or weight-bearing by the age of 12-14 months should be encouraged to use a standing frame to help them weight bear. 

    If appropriate, children can start using standing frames from as young as 9 months, but you will be guided by your medical team on the best time for your child.

  • How long should my child stand in order to gain the benefits of standing?

    The question of how long to stand is one of the most common questions, but also a very difficult question to answer. This is because children use standing frames for lots of different reasons, and the optimum times can vary depending on their focus. 

    Typically, the average recommendation would be to gradually work up to standing for 30-60 minutes daily, for a minimum of 5 days per week. However, your child’s physiotherapist will advise you on what is most appropriate for your child and their goals.

  • Are there any reasons not to stand?

    There are very few reasons not to stand, but some reasons include:

    • Current fractures
    • Postoperative weight bearing restrictions
    • Pain and discomfort that cannot be resolved by the adjustment of support or better positioning

     

    Children can still use a standing frame if their hips are subluxed (where the ball has partially come out of the socket) or dislocated (where the ball has completely come out of the socket), in the absence of pain. However this decision should be taken in consultation with your orthopaedic consultant. As with anything, if in doubt, always check with your child’s medical team.

  • My child struggles to fully straighten their knees. Can they still use a standing frame?

    At the moment, there is no definitive guidance of at what point a child should stop using a standing frame if they struggle to fully straighten their knees or hips. 

    Inability to straighten a joint is known as a joint contracture, and there is a common perception that if a child’s knees or hips have 30 degrees contractures or less then they are still able to use a static frame. However, you should always liaise with your child’s orthopaedic consultant if you have concerns about this.

  • What is the best angle for standing?

    The “best” angle (also known as inclination or tilt) for standing all comes down to your child’s abilities. The more upright a child can tolerate standing, the greater the load bearing through the feet and therefore the greater the impact of the benefits of standing.

    On average, children bear 76% of their body weight when positioned in a standing frame, but there is a large range and there are many differences between standing frames, with each offering their own benefits. Generally speaking, the inclination or tilt of the standing frame does not significantly impact weight bearing, as long as the tilt is 70 degrees or more upright. 

    One useful rule of thumb is that you should not be able to move your child’s foot, once they are in a standing position.

References

  1. Katz D, Snyder B, Federico A, et al. Can using standers increase bone density in non-ambulatory children? Dev Med Child Neurol. 2006;48(S106):9.
  2. 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):1392-1399.
  3. Goodwin, J., Colver, A., Basu, A., Crombie, S., Howel, D., Parr, J. R., … Cadwgan, J. (2018a). Understanding frames: A UK survey of parents and professionals regarding the use of standing frames for children with cerebral palsy. Child: Care, Health and Development, 44(2), 195–202.
  4. Rivi, E., Filippi, M., Fornasari, E., Mascia, M. T., Ferrari, A., & Costi, S. (2014). Effectiveness of standing frame on constipation in children with cerebral palsy: A single‐subject study. Occupational Therapy International, 21(3), 115-123.
  5. 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):316-323.
  6. Salem Y, Lovelace-Chandler V, Zabel RJ, McMillan AG. Effects of prolonged standing on gait in children with spastic cerebral palsy. Phys Occup Ther Pediatr. 2010;30(1):54-65.
  7. Taylor K. Factors affecting prescription and implementation of standing-frame programs by school based physical therapists for children with impaired mobility. Pediatr Phys Ther. 2009;21(3):282-288.

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