As Lisa Kenyon, PT, DPT, Ph.D., PCS, joined our Google Meet interview, I caught a glimpse of her workstation, which included an elevated platform, perhaps large enough to hold a laptop.
“I’ve been standing for my other meetings today,” she said, taking a seat at her desk. Before our interview even began, Kenyon was demonstrating the value of standing throughout the day.
A timeline for pediatric standing
Kenyon, a professor in the Department of Physical Therapy and Athletic Training at Grand Valley State University in Grand Rapids, Mich., is a member of the American Physical Therapy Association’s (APTA) Pediatric and Education sections, and the American Academy of Cerebral Palsy & Developmental Medicine.
Regarding the timing of a pediatric standing program, Kenyon said, “There are really so many factors that come into it. Ideally, what I want to do is try to enable the child I’m working with to do the same activities that other children their age do — maybe just in a different way. So ideally, about the same time typically developing children are starting to stand, I should be thinking, ‘How am I going to get standing into the child’s life?’”
Kenyon pointed out that well before children begin to walk, they show interest in standing. “Think about the typically developing infant who’s sitting on your lap, and you’re holding them, and they’re wanting to stand,” she said. “Or you’re getting the infant off the changing table, and they pull all the way up to standing. Your typically developing child is really doing a lot of supported standing through the help of an adult or their couch or their crib before their first birthday.”
A standing regimen could be helpful to a child’s development even if the child is expected to eventually stand independently. “We know that for the child who’s going to be a little bit delayed in their mobility, some standing is still important,” Kenyon said. “We may not necessarily do it with as much equipment. We might do more supported standing: Standing at the couch is a therapeutic activity for those children who maybe are just going to walk a little later.”
When children are going to be more significantly delayed in learning to walk — around age 2 or older — “I begin to think about equipment,” Kenyon said. “And for those who aren’t going to be walking, I begin to think about it even earlier, because again, I want to try to get them up and standing when their typically developing peers would be. So about 12 to 14 months of age, ideally.
“For children who have severe cerebral palsy — children who are Gross Motor Function Classification System Level IV or V, or other conditions that present similarly and are just not cerebral palsy — we should be starting standing by about 12 months of age.”
Kenyon added that before going too far into a conversation about standing, she checks in with the child and family. “I also want to make sure that these are, of course, activities that they want to do or their family wants to do. Sometimes I’ll talk to therapists, and they’ll say, ‘I want them to be able to do this.’ I ask, ‘Does the child want to do that?’ You want to make sure the child’s on board.”
The benefits and impact of standing
While there isn’t substantial information yet on the benefits of standing for young children, “For the older child, we have good evidence to suggest that standing programs — if we pay good attention to our dosages — can have an effect, if we reach a high enough threshold with those doses,” Kenyon said.
For example, enough minutes of supported standing can impact bone mineral density, Kenyon said, adding, “It can also help hip stability, particularly if we have them in a certain degree of total bilateral hip abduction, which means having their legs apart. Also, it can help range of motion, mainly of the hip, knee, and ankle, and even with spasticity. We know that those things are going to be helped if we can get these appropriate doses. There are different doses for different outcomes.”
Standing is also the gateway to performing a range of activities of daily living (ADL), including self-care activities.
“We do so many things in standing,” Kenyon pointed out. “We stand in the morning to get out of bed. We stand in front of the mirror to do our toothbrushing or fix our hair. We stand to do ADLs in the kitchen — cooking and things like that. We stand to get something off of a high shelf or out of the refrigerator. I think we forget about standing as a function.”
Creating safe standing scenarios
What about contraindications for pediatric standing?
“First of all, especially if a child hasn’t been standing, I want to make sure that it’s safe, especially as a child gets older,” Kenyon said. “They may have brittle bones. They may have osteoporosis, and I need to be very, very careful about putting them right into a standing position. I usually work very closely with the medical team, that child’s physician or orthopedist. I’m making sure that it’s safe for the child to stand. If, for example, it’s an 11-year-old girl who’s never stood before, I’m going to really look at making sure it’s safe for her.”
And during the standing process or trial, Kenyon keeps observing. “I want to look at the range of motion. Can they tell me if they have pain, and if they do stand, do they seem to have pain? Do they have orthostatic hypotension, where they come into standing and they get faint because they’re just not used to having their blood needing to pump in that direction? We tend to think about those things with adults, but not necessarily with children as well.
“If we aren’t careful, we could cause a tendon to rupture, or a fracture, or we could have a child pass out if we’re not recognizing the orthostatic hypotension. So as much as I want to get these kids standing, I have to do it through the lens of safety and what’s appropriate for them in their situation.”
Kenyon also asks about orthoses. “If the doctor told the child’s parents that [the child] shouldn’t be standing without his ankle-foot orthoses on, then I’m going to make sure he’s standing with the ankle-foot orthoses in any stander that I provide for him, whether it’s a power wheelchair standing device or static stander.”
No matter how eager the child or family might be about a standing regimen, Kenyon emphasized the need to put safety first. That process could mean progressing to a standing position more slowly, in stages.
“Definitely we would try different gradations,” Kenyon said, in possibly taking a more measured approach. “If the child’s small enough, I may just try having them supported by me while standing. I want to make sure that I’m doing these things in ways that are safe. So even if a family is [very enthusiastic], I’m going to put the brakes on until I determine in my professional judgment that it’s safe. There’s not really a list of things that I’m looking for. It’s a pattern that comes together, and as a licensed professional I have an obligation to ensure safety.”
Standing technology choices
Current standing equipment choices include static standing frames, standing frames that can be propelled by the child or caregiver, and power standing functions on power wheelchairs.
For very young children, there are additional early-intervention choices, including the Permobil Explorer Mini and ride-on toys modified via the GoBabyGo program.
The Explorer Mini, with straddle-style seating, allows its young riders to either sit or stand while driving. “It provides them with some support,” Kenyon said of the Explorer Mini. “The alignment isn’t going to be quite as well controlled as in a device that was meant for you to be standing for a long periods of time.”
While GoBabyGo vehicles — switch-driven devices created by adapting power ride-on toys — typically are driven with the child seated, some vehicles have been modified to promote standing.
“I think there’s a lot of different ways that we can get standing into a young child’s life,” Kenyon said. “There was even a project done, I believe it was by Dr. Sam Logan, where they adapted [ride-on power toys] so that the child had to be standing for the device to go.”*
Static standing frames can offer the physical benefits of standing — bone mineral density, range of motion, etc. — though some ADLs “can be difficult to do in a static stander, but we can maybe think about different ways to be mobile in the standers,” Kenyon said. “There are standers that have big wheels that children can push, if they’re able to do that. There are power wheelchairs that have a standing feature attached to them. We call them power wheelchair standing devices, and they convert between sitting and standing and can be driven in either position.”
Standing also expands the child’s literal reach and related abilities, Kenyon said. “Sitting really restricts somebody to just functioning in a horizontal plane. There is some evidence that suggests that short bursts of standing during the day or longer bursts of standing during the day with the children in a static stander actually are helping to contribute to light physical activity and are decreasing the sedentary behavior of just sitting. I think that is really an exciting thing.”
How standing can impact children’s lives
While the physical benefits of standing are significant, Kenyon also praised its potential social and emotional benefits.
“They can see different things,” she said of the change of positioning for kids. “Some of the children that we’ve worked with who used the power wheelchair standing devices have talked about ‘I could go to the museum, and I could stand and see something, I could go to the racetrack, and I could stand and see just like everybody else.’
“This is something that we don’t necessarily think about all the time — standing as a sense of belonging, and the children who can transition themselves between sitting and standing using the power wheelchair standing device. If they’re in a church and someone says, ‘Okay, everybody stand,’ they can make that decision if they’re going to stand. If they’re at the baseball game or the hockey game or at school and they’re doing the Pledge of Allegiance or the national anthem, they can decide to stand. We’ve had a lot of children tell us how much that makes them feel like they belong in the community rather than setting them apart.”
Kenyon is a fan of the autonomy that power standing wheelchairs can offer young wheelchair riders.
“One young man who went to a concert for a very popular Christian band was so excited because he had been to concerts like that before, but he couldn’t stand. But this time when they said, ‘Everybody stand,’ he could stand up. And then when they said, ‘Okay, you can be seated,’ he could sit back down. That was just so exciting for me to hear that he felt so in touch with that spiritual activity because of a piece of equipment.”
Making their own decisions
That ability to move from sitting to standing on demand can be so important to families, Kenyon added.
“In one of our qualitative studies about power wheelchair standing devices, one of the moms — and I thought this was just so insightful — said that with the power wheelchair standing device, [her child] can stand when he wants and where he wants,” she said. “He doesn’t have to say, ‘Could you excuse me for a second while somebody transfers me into this other piece of equipment?’
Ultimately, greater autonomy for children at any and all ages can be empowering and priceless. Kenyon recalled working with a gifted, ambitious student who needed to take high school chemistry — in a classroom with elevated lab tables — to achieve the college goals she’d set for herself.
“The power wheelchair standing device enabled her to be able to take chemistry and get an A,” Kenyon said. “I’m sure that the school would have been required to make some sort of modification, but she liked that they didn’t have to. She could stand.”
*Study: Standing Tall: Feasibility of a Modified Ride-On Car That Encourages Standing, by Samuel W. Logan, et al, National Library of Medicine, Jan. 2019. https://pubmed.ncbi.nlm.nih.gov/30557294/
Editor’s note: This story was originally published in Mobility Management’s spring 2024 digital magazine. Subscribing to Mobility Management’s free newsletter, eMobility, includes a free digital magazine subscription.
Image: istockphoto.com/tonefotografia