Pediatric Series

The Power of Early-Intervention Positioning

Providing Infants & Toddlers with Proper Positioning — & Positioning Options — Can Impact Their Whole Lives

Early-Intervention PositioningIn complex rehab technology circles, discussion of early intervention for very young children often centers around independent mobility in the form of manual or power wheelchairs. Providing infants and toddlers with the means to explore their environments on their own terms, experts say, is crucial to their cognitive, social and emotional development.

But there’s more to early intervention than wheeled mobility. Young children can also benefit from early-intervention positioning and alternate positioning. And as with independent mobility, earlyintervention alternate positioning can also result in a range of benefits, including clinical ones.

The Role of Standing in Child Development

Every child is different of course, but generally speaking, by around the 9-month mark babies begin pulling themselves into a standing position with the aid of a coffee table, sofa or other furniture. This is an exciting developmental milestone for babies, giving them literally a whole new view of their environments, and increased access to it, as well.

But Amy Morgan, PT, ATP, Permobil’s pediatric & standing specialist, points out that standing also has a range of physical benefits.

“The biggest one that comes to mind is the development of the hip joints,” Morgan says. “When a baby is born, the acetabulum — it’s the socket of the hip, where the femur goes into the pelvis, and that makes the hip joint — is very flat. If you take an x-ray of a baby’s pelvis, you’ll see flat areas there.”

The acetabulum develops, Morgan says, through a range of mobility-related activities. “As a child goes through typical developmental sequences — including weight bearing on hands and knees in the quadruped position, and crawling, in combination with standing — all of those forces that act upon the pelvis as the baby is moving develop that acetabulum.”

Failure of the acetabulum to fully and properly develop can cause a variety of problems, Morgan adds.

“The deeper the acetabulum, the more secure the hip joint is. So what you see is kids with cerebral palsy (CP), for example, having a very high incidence of hip dysplasia. Maybe their acetabula didn’t develop and go through those sequences as they should, so maybe they remain shallow. There’s some depth to them, but overall they remain pretty shallow, and so the femurs can easily be displaced out of those sockets. The other combination that adds into that is spasticity, so the spastic muscles are pulling the femurs out of the sockets.”

Andy Hicks, ATP, SMS, CAPS, Altimate Medical’s eastern regional manager, says standing can impact a range of pediatric skills and abilities.

“When we developed our pediatric education program, we looked at how standing and position change can affect development, and were surprised at the strength of the studies indicating several developmental benefits,” Hicks says. “One of the primary benefits is how standing can improve overall motor skills.

“Children that are in a consistent standing program had better sitting skills, lying skills and upper-extremity coordination than children that did not stand. So they could sit on the commode with more independence or are more capable of moving in bed. Standing gave the children better proprioception, or a better understanding of their body in space and how to control it to their best ability. This gives them a significant improvement in bilateral upper-extremity activities, which translated to improved ADL skills.”

Postural Benefits from Standing

Morgan adds that standing also can lead to overall postural benefits.

“Being in an upright position challenges postural muscles differently than being in a supine or even in a seated position,” she notes. “One can argue that in trunk stability and trunk postural control, (sitting and) standing have similar benefits. But there’s definitely a difference when you get up into a standing position as far as the ability to activate muscles that cross the hip joint. They’re in a different position to allow them to be activated differently.

“Some of the major muscles that give us balance and allow us to balance are our gluteal muscles and our postural extensors. So when you’re standing, you’re able to activate those glutes and maybe assist with other stability and stabilization activities of the trunk.”

Those postural benefits extend to the upper body as well, Hicks says.

“One of the first motor control challenges for babies,” he points out, “is to hold their heads up to look around. Children with CP continue to have challenges with coordination and strength to hold their head up, and many — up to 75 percent — have poor vision. Standing can help children develop stronger and more controlled head movement to help with their field of vision, as well as bring them up closer to people and objects, like a smart board.”

In addition to the physical benefits of standing, of course, there are many social and emotional benefits.

“Definitely supported by observations and experience,” Morgan says, “is that there’s increased arousability when a child is standing, that they’re more engaged, more awake and more likely to engage in activity. So that’s another benefit of getting upright, into that standing position.” Hicks concurs: “Another simple benefit (is that) standing allows a child to see, interact and play more engagingly with their siblings/classmates than in a sitting position.”

When Should a Standing Regimen Begin?

Since children without disabilities start standing at a very young age, ideally, standing intervention should refl ect that developmental timeline.

“Any child that is 1 year old and cannot stand because of a neurological impairment should be evaluated for a stander for physical and developmental reasons,” Hick says. “Caution should be given to children that are in poor general health. If there seems to be pain when standing or the child had recent surgeries, caution in positioning pads should be taken so pressure is not applied to the area of a G-tube or Baclofen pump.”

“I always like to bring it back to the typically developing infant and what they are doing,” Morgan says in regard to determining when children could be ready for standing intervention. She notes that typically developing infants are “rolling around. They may get up on their hands and knees and rock. They may pull to stand. But even before they’re pulling to stand on their own, they’re standing in ExerSaucers and different types of baby toy standing apparatuses. Therapists will argue — is that good for the hips? Is that bad for the hips because it puts hips into this kind of abducted, externally rotated position?”

Morgan says the “jury’s out” on whether such mainstream standing toys are beneficial, but adds, “the fact of the matter is they are upright in an extended position with their feet on the floor. Obviously, we’d like the alignment of the hips to be more neutral, but they’re still experiencing that activity, a standing position.”

She explains that learning to balance and control one’s body starts with extension: “Babies are experimenting with that balance of flexors and extensors, but what they know first is extension. Even with very young infants, that’s what they do because those extensors are the primitive muscles, and they’re activating and starting to learn how to control and use them.”

Children with neurological insults, she says, “may have trouble controlling those muscles. Typical babies learn to control them pretty quickly. They have the ability for their brain to get the correct signals to their muscles to learn to manage that. With children with CP or some other type of condition, that connection between the brain and the muscle — whether it’s at the brain level, at the spinal cord level or the muscle level — that connection is disrupted, so it’s more difficult. But they still need to be in that position to try to make those signals connect appropriately.”

With infants, Morgan says, therapists might use other means and equipment to provide that sort of experience.

“When I was doing developmental therapy,” she says, “we’d use things like bolsters. We’d put the babies prone over the bolster, on their bellies, and kind of rock it back, supporting their trunks and heads and allowing their feet to be on the ground in the weightbearing position.

“Those are some of the interventions and home programs we would teach families to do, to get them to do this weight bearing. Weight bearing also has a spasticity management or tone management component because it’s putting proprioceptive input through the joints. When you do it with a bolster or even in a stander with a tray, you can get that weight bearing through the upper extremities as well as through the lower extremities.”

Making a Gradual Transition

While there are many benefits of standing, the rehab team does need
to keep in mind that different children will respond differently to this
new positioning.

“The reactions are varied,” Hicks says. “Some children enjoy standing to have a different perspective and experience; others have a harder time adapting to it. As with any child at a young age, they will likely need adult interaction and distraction to gain more time standing.”

Fortunately, Morgan says, standing even for shorter periods can result in significant benefits.

“From the research I’ve seen — not necessarily in early intervention, but just with standing — the better pattern is to stand more frequently for shorter durations during the day,” she says.

She again takes cues from the way typically developing infants and toddlers change positions all day long, from sitting to crawling to pulling to a stand, then going back to sitting.

“Think about kids getting in and out of different postures and positions,” she says. “Th at’s actually preferred. The problem is when you have a child who’s completely dependent — it’s not easy for a parent and a family to switch them back and forth all throughout the day. So they usually end up standing for a longer duration. But if they can’t tolerate that, it doesn’t mean they didn’t benefit from that activity.”

Hicks notes that research indicates that with standing, “more is better, and the rule of thumb is to try to have a consistent standing program that can grow into one hour per day. But much like exercise, the age, the strength and tolerance of the child have to be taken into consideration. Also, the child has to work up to (standing for longer periods) over time, because it can be taxing in the beginning. To gain strength and standing tolerance, children should be allowed therapeutic rest within the standing program. For example, if the child is having problems maintaining head control, then they should be allowed to rest by reclining back so their neck muscles can recover when the head is on the headrest. Sadly, some insurance and state funding agencies will only pay for an upright stander for young children, so they must get out of the stander to rest, which makes it harder for the caregiver and harder for the child to stand enough to gain endurance and obtain the full benefit from standing.”

When introducing standing into a child’s regimen, Morgan also recommends making a gradual transition.

“With the younger child or the person that’s extremely dependent and difficult to transfer into a sit-to-stand stander, I like to do more of the supine positioning standers,” Morgan says. “Th at’s a position they’re used to being in. They’re used to lying down. They can lie down and get the straps on them and secure, and then you gradually elevate them. They have the same risk of blood pressure drop as an adult would, so you have to monitor them physiologically to make sure they’re tolerating that activity, and the way you do that is by very slowly progressing them and gradually bringing them up to a standing position.

“Some children with severe respiratory issues may desaturate when they’re in a standing position, so you have to watch their oxygen saturation, make sure that they’re doing OK from that perspective.”

Trying a tilt table first for someone using a supine standing model can be helpful, she added. The child, she explains, is probably thinking, “I’m used to the ceiling as my reference point, and now I can’t see it anymore.”

The Joys of Standing

A child who is able to stand gives his or her clinical team some new and potentially therapeutic opportunities.

“The last thing you want is for somebody to get a stander and stand all day,” Morgan says. “That’s like sitting all day. But a standing device would give another option for that baby instead of being in the swing all day or the adaptive chair or the wheelchair. It gives them another option for a different position to be in.

“The OT or the speech therapist might say, ‘Wow, she can manage her food or suck or swallow much better when she’s weight bearing on her feet. Instead of feeding her in her feeder chair, let’s try to do some feeding while she’s in her standing frame.’ It’s totally individual for the client.”

Toddlers seem to be constantly moving and changing positions. Morgan points out that they’re good role models.

“They’re transitioning in and out of positions all day long. The more we can mimic the activities of a typically developing child, the better it’s going to be.”

This article originally appeared in the April 2012 issue of Mobility Management.

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