Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach Throughout the Lifespan xx (2021) x–xx 1

DOI:10.3233/PRM-190660
IOS Press

1 Research Article

2 Inclination, hip abduction, orientation, and

tone affect weight-bearing in standing

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4 devices
5 Ginny Palega,∗ , Wendy Altizerb , Rachel Maloneb , Katie Ballardb and Alison Kregerc

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a Montgomery County Infants and Toddlers Program, Rockville, MD, USA
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b MilestonesPhysical Therapy, Hurricane, WV, USA
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c Wheeling University, Wheeling, WV, USA

9 Abstract.
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PURPOSE: With children who are unable to stand or walk independently in the community, therapists commonly use standing
10
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11 devices to assist lower-extremity weight-bearing which is important for bone and muscle health. In addition, positioning in
12 hip abduction may improve hip stability and range of motion. This is the first study to explore the effect of angle of inclination,
13 hip abduction, body orientation, and tone on weight-bearing in pediatric standing devices.
14 METHODS: This descriptive exploratory study used a convenience sample of 15 participants (2 with normal tone, 5 with
15 generalized hypotonia, and 8 with hypertonia) (mean age of 5 years and 10 months, range of 3 years 4 months to 9 years 7
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16 months); 13 of whom used standing devices at home, as well as 2 typically developing siblings (normal tone). Each child
17 stood in 36 positions to measure the amount of weight-bearing through footplates.
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18 RESULTS: Weight-bearing was highest with 60 degrees of abduction and no inclination (upright) in supine positioning for
19 children with low and normal tone. Children with high muscle tone bore most weight through their feet with no abduction
20 (feet together) and no inclination (upright) in prone positioning. Overall, supine positioning resulted in more weight-bearing
21 in all positions for children with low and normal tone. Prone positioning resulted in slightly more weight-bearing in all
22 positions for children with high tone.
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CONCLUSIONS: Weight-bearing was affected by all three of the variables (inclination, abduction, and orientation) for
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participants with high, normal, and low tone. To determine optimal positioning, all standers should include a system to
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measure where and how much weight-bearing is occurring in the device.
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26 Keywords: Standing, stander, hypotonia, hypertonia, abduction

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27 1. Introduction and literature review mend standing programs for children who are limited 32
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ambulators or non-ambulatory and cannot stand 33

28 When children are unable to ambulate indepen- unsupported for functional activities. Weight-bearing 34
29 dently in the community, they are at risk for low is one of the most often cited reasons for the use of 35
30 bone mineral density (BMD), pathological fractures standing devices in schools [3], yet only two prior 36
31 [1] and contractures [2]. Therapists often recom- studies have measured how much weight-bearing 37

∗ Corresponding
occurred [4, 5]. Load bearing through the legs with 38
author: Ginny Paleg, PT, DScPT, Montgomery
County Infants and Toddlers Program, 420 Hillmoor Dr, Silver
resultant muscle contractions is thought to be the 39

Spring, MD 20901, USA. Tel.: +1 3014524656; E-mail: ginny@ mechanism for stimulating bone growth and thus 40

paleg.com. increases BMD [6]. Standing five times a week may 41

ISSN 1874-5393/$35.00 © 2021 – IOS Press. All rights reserved.

 2 G. Paleg et al. / Inclination, hip abduction, orientation, and tone affect weight-bearing in standing devices

42 decrease spasticity, assist in maintaining hip and knee neither described nor detailed. Also, the influence of 94

43 range of motion (ROM), and increase and/or maintain inclination and orientation was not explored. Clini- 95

44 hip stability [7]. cians report many reasons for choosing prone versus 96

45 Pountney and colleagues described an associa- supine positioning and/or varied inclination positions 97

46 tion between improved hip stability and positioning in standing devices [3]. There is little research to sup- 98

47 in moderate hip abduction in standing, sitting, and port this reasoning. To date, no studies have measured 99

48 lying positions [8, 9]. Three other studies [10–12] or compared weight-bearing during differing degrees 100

49 suggested standing with the legs abducted 60◦ (30◦ of hip abduction or at different inclinations while 101

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50 away from the midline for each leg) prevents and standing. They also have not explored the influence 102

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51 even improves hip subluxation as well as prevents hip of body orientation or tone on weight-bearing. 103

52 ROM loss and adductor contractures in children with The purpose of this study was to explore the 104

53 cerebral palsy. However, therapists and participants effects of three differing angles of inclination (upright 105

54 report 60◦ of total abduction can be uncomfortable [0◦ ]/15◦ /30◦ ), hip abduction (feet together [0◦ ]/30◦ / 106

55 [12]. The rationale for the influence of hip abduc- 60◦ total of bilateral hips), and body orientation 107

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56 tion on hip stability comes from the femoral head (supine vs prone) in individuals with different types of 108

57 applying force to the growth plate of the acetabulum, muscle tone (high, low, normal) on amount of weight- 109

58 with resultant bone response leading to more nor- bearing through the feet in two of three models of 110

59 mal development. With abduction, the femoral head standers. 111

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60 becomes more covered by the acetabulum and may
61 lead to more normal development of the neck of the
62 femur [13]. Although the research evidence is weak or 2. Methods 112

63 very weak, systematic reviews suggest hip abduction

64 may be considered as part of postural management Institutional Review Board approval was obtained 113
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65 programs [14, 15]. This has led to widespread use prior to data collection from Wheeling University. 114

66 of hip abduction in standing programs without fully This was an exploratory descriptive study. Partic- 115

67 understanding its effects on weight-bearing. ipants were recruited from one therapist’s caseload 116

68 Standing devices, commonly referred to as as a convenience sample of all children who rou- 117

69 standers, are defined as durable medical equipment tinely used standing devices at home and received 118

which support the feet, knees, hips, and trunk, so the physical therapy at one outpatient physical therapy
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70 119

71 user can remain upright in biomechanical alignment clinic. Participants were excluded if they had a history 120
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72 [16]. Standing devices are commonly used in schools, of uncontrollable seizures (>30 per day), autonomic 121

73 clinics, hospitals, homes, and other community set- dysreflexia, oxygen saturation measured by pulse 122

74 tings to positively impact body structure and function oximetry below 90 percent, or skin concerns (redness 123

75 [7]. Some models allow the user to transition from a or open lesions). 124

76 sitting position to standing and some can accommo- Typically developing siblings who attended clinic 125
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77 date up to 45◦ of flexion contracture at the hip, knee, on the data collection day were also recruited as a 126

78 and/or ankle. A few standing devices allow for hip comparison group. Children and their families were 127

79 abduction up to 30◦ on each side (60◦ total). Some advised of the opportunity to participate during their 128

80 standers are set in a fixed orientation (supine, upright, therapy session immediately prior to the data collec- 129
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81 prone) while others allow for all three orientations tion day. 130

82 (multi-positional). Recently, some dynamic models Descriptive data was collected on all participants 131

83 (ones that allow for active dorsiflexion, rocking ante- at the start of the session including age, sex, diagno- 132

84 rior/posterior, and leaning in all directions) have sis, weight, and muscle tone. Typically developing 133
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85 been developed. There are also models that do not siblings were determined to have normal tone via 134

86 accommodate abduction but have wheels or power physical exam. Hypertonia (or high tone) was defined 135

87 for independent mobility while standing, as well as as an “increased stretch reflex” [17] in both elbows 136

88 wheelchairs that allow the person to be positioned in and knees. Hypotonia was determined using the def- 137

89 various stages of sit-to-stand, including upright. inition of “Hypotonia Syndrome” [18] in addition to 138

90 Two prior studies that directly measured weight- the participant having at least 5 out of 8 of the follow- 139

91 bearing found that subjects bore 78% [4] and 68% ing findings: decreased strength, hypermobile joints, 140

92 [5] of their body weight in their feet while using increased flexibility, delayed motor skills, leaning 141

93 standing devices. In these studies, positioning was on supports, rounded shoulders, decreased activity 142
 G. Paleg et al. / Inclination, hip abduction, orientation, and tone affect weight-bearing in standing devices 3

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Fig. 1. Conditions and Design of Study.

143 tolerance, or decreased attention/motivation. Partici-

144 pant’s total weight was measured immediately prior

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145 to data collection by placing the participant fully
146 clothed (with shoes and orthotics) supine on a scale
147 (WC Redmon Pet Scale from Amazon.com). This Fig. 2. Three Standers used in study; Zing, HLT Superstand, Stanz.
148 scale was calibrated with a five-pound weight before

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149 each child was weighed. Study risks and benefits were weight at the beginning of each measurement series. 183

150 reviewed with each family and child. Parent consent The child was placed in the stander by their regular 184

151 and child assent to participate was obtained prior to therapist, who positioned feet, ankles, knees, hips, 185

152 start of data collection. and pelvis in alignment. If the participant typically 186

153 Each participant chose index cards from a tray used orthotics during their standing program, these 187
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154 which randomized their order of conditions including were used during data collection. The Face, Legs, 188

155 brand of standing device, inclination (0◦ /15◦ /30◦ ), Activity, Cry, and Consolability Scale (FLACC) scale 189

156 amount of abduction (0◦ /30◦ /60◦ ), and orientation was administered to ensure that children were com- 190

157 (prone/supine) (see Fig. 1 for study design and fortable and not experiencing pain (particularly for 191

158 conditions). Total weight-bearing was measured by those children not able to express this verbally). The 192

two digital postal scales mounted on the stand- FLACC scale has been shown to be valid and reliable
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159 193

160 ing device footplate, one beneath each foot (Smart in measuring pain and non-pain distress in children 194
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161 Weigh Digital Shipping and Postal Weight Scale from [19]. 195

162 Amazon.com) on the standing devices. Weight mea- After achieving body alignment in the standing 196

163 surements from both scales were added together and device, the randomized conditions of inclination and 197

164 divided by participant’s total weight and represented abduction were applied. Leg internal/external rota- 198

165 as a percentage. tion was not controlled. The sole of the shoe always 199
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166 This study used three standing devices: 1) Jenx maintained contact with the scale. The positioning 200

167 Standz, 2) EasyStand Zing, and 3) Prime Engineering therapist conducted the FLACC at each position to 201

168 HLT Superstand with Abduction System (see Fig. 2). ensure the child was comfortable and willing to con- 202

169 They were all multi-positional standers allowing up tinue with the study. Inclination was measured at each 203

to 30◦ hip abduction of each leg (60◦ total) and 30◦ of

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170 position using an inclinometer (Tilt Meter App for 204

171 inclination. Each participant was positioned in two of iPhone). Angle of abduction was determined by mea- 205

172 the three standers. Devices were chosen out of con- suring the inseam length and ensuring this equaled the 206

173 venience, as they were loaned free-of-charge by the distance between the feet. This configuration resulted 207
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174 manufacturers and their footplates accommodated the in an equilateral triangle, in which each angle is 60◦ . 208

175 mounted scales. The investigators removed the heel When the distance between the feet was half the mea- 209

176 cups and straps from all three models and mounted the surement of the inseam, the angle between the two 210

177 digital scales on the footplates (See Figs. 3A and 3B). femurs (abduction) was determined to be 30◦ total. 211

178 Five therapists were involved in data collection. This methodology was developed by Doug Nunn, 212

179 One recorded all data while the other four positioned PT at the Perlman Center at Cincinnati Children’s 213

180 subjects and called out weight values. Inter-rater reli- Hospital [20]. 214

181 ability was established during a practice session. Each Each subject was randomized to be placed 215

182 scale was set to “zero” and calibrated with a 5-pound in prone or supine positioning and then moved 216
 4 G. Paleg et al. / Inclination, hip abduction, orientation, and tone affect weight-bearing in standing devices

lasted 45–60 minutes, with all 15 sessions taking 222

place over a single day (see Fig. 4). 223

2.1. Data analysis methods 224

The data were analyzed as a percentage calculated 225

by dividing the total weight registered on the foot- 226

plates (sum of two scale measurements) by the child’s 227

total weight. Data were sorted by supine/prone posi-

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tion, amount of incline (0◦ /15◦ /30◦ ), and amount of

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abduction (0◦ /30◦ /60◦ ). Means, ranges, and standard 230

deviations were calculated using Microsoft Excel 231

2020. 232

There is currently no published information about 233

weight-bearing and clinically meaningful change.

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234

The literature does discuss non-weight-bearing and 235

“toe-touch” weight-bearing in relation to adult ortho- 236

pedics. In this body of literature, 10% weight-bearing 237

and below is considered non-weightbearing [21], 238

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therefore we have used 10% change in weight- 239

bearing as clinically meaningful change. 240

3. Results 241
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Fifteen participants (13 who used standing devices 242

regularly and two siblings) consented to and com- 243

pleted the study. Two presented with normal tone 244

(typically developing siblings of participants used as 245

a comparison group), 5 had hypotonia, and 8 had

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hypertonia. The average age of the sample was 5 years 247

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and 10 months (range 3 years 4 months to 9 years 248

7 months). Participants who regularly used standing 249

devices had a variety of diagnoses including cere- 250

bral palsy with Gross Motor Functional Classification 251

System Levels III-V, spinal cord injury, congen- 252

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ital cytomegalovirus infection, hypoxic ischemic 253

encephalopathy, agenesis of the corpus callosum, and 254

hydrocephalus (see Table 1). All 15 participants com- 255

pleted all 36 measurements. FLACC scores remained 256

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unchanged, and no children or parents requested to 257

stop. There was no missing data. 258

Individual weight-bearing ranged from 35.0% to 259

133.0% (mean = 91.35%). Data points over 100% 260

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occurred in all groups, with the majority in partici- 261

Fig. 3. A Photo of Data Collection. B Stander Set-Up with Digital
Scales Mounted on Footplates. pants with high tone in all positions and in all groups 262

with feet together and no inclination (See Table 2). 263

A weight measurement of over 100% cannot be fully 264

217 passively in randomly assigned order of inclination explained. This may result when the child “pushes” 265

218 (0◦ /15◦ /30◦ ) and abduction (0◦ /15◦ /30◦ ). This pro- on the body supports and down through their feet, as 266

219 cess was repeated for the second randomly selected there would need to be some force production to get a 267

220 stander for a total of 36 position combinations per reading over 100%. Readings over 100% were seen in 268

221 stander (72 total per child). Each participant session two similar studies [11, 12] and were not unexpected. 269
 G. Paleg et al. / Inclination, hip abduction, orientation, and tone affect weight-bearing in standing devices 5

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Fig. 4. Weight-Bearing in All Positions.

Table 1
Participant Characteristics
Subject weight GMFCS Age tone Dx Standers

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1. 74.8 IV 6 yrs 8 months hypotonia CP Zing 2 Standz 3
2. 78.8 n/a 8 yrs 1 months hypotonia SCI Zing 2 Standz 3
3. 71 IV 9 yrs 7 months hypertonia CP Zing 2 Standz 3
4. 73.2 n/a 8 yrs 9 months typical control Zing 2 Standz 3
5. 32.1 III 4 yrs 11 months hypertonia CP Standz 2 Zing 3
6. 28.1 V 6 yrs 7 months hypotonia
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7. 31.4 IV 4 yrs 2 months hypertonia CMV Zing 2 HLT Superstand 1
8. 26.1 IV 3 yrs 4 months hypertonia CP HLT Superstand 1 Standz 3
9. 21.0 IV 7 yrs 1 months hypertonia CP Standz 3 Zing 2
10. 34.0 V 3 yrs 11 months hypertonia HIE Standz 3 HLT Superstand 1
11. 28.0 V 3 yrs 11 months hypotonia Agenesis corpus callosum HLT Superstand 1 Zing 2
12. 32.1 V 7 yrs 11 months hypertonia CP Standz 3 HLT Superstand 1
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13. 24.1 IV 4 yrs 3 months hypotonia Hydrocephalus Standz 3 HLT Superstand 1

14. 39.2 n/a 3 yrs 10 months typical control Zing 2 HLT Superstand 1
15. 26.2 III 4 yrs 6 months hypertonia CP Zing 2 HLT Superstand 1
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Table 2
Number of participants weight-bearing over 100% in each position
Prone Supine
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Abduction Neutral 30◦ 60◦ Abduction Neutral 30◦ 60◦

Inclination Inclination
Upright 3(HHH) 4(HLN) 4(HLLN) Upright 5(HHHLN) 8(HHHHLLNN) 6(HHLLNN)
15◦ 3(HHH) 2(HH) 2(HH) 15◦ 2(HH) 4(HHLL) 6(HHLLNN)
30◦ 30◦
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1(H) 0 1(H) 2(HH) 1(H) 2(HL)

Key: H = High Tone, L = Low tone, N = Normal Tone.

270 However, these data points may have skewed results when upright with 60◦ of abduction in supine posi- 280
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271 to show more weight-bearing than occurred. Since tion and the least (65%) with 30◦ of inclination, feet 281

272 these data points occurred in all groups, it should not together in prone position (see Fig. 6). The children 282

273 have affected the overall findings. with typical tone demonstrated the most weight- 283

274 The high tone group demonstrated the most bearing (108%) when upright with 60◦ of abduction 284

275 weight-bearing (91%) when upright with feet to- in supine position and the least (69%) with 30◦ incli- 285

276 gether in prone position, and the least weight-bearing nation, feet together in prone position (see Fig. 7). 286

277 (67%) with 30◦ of inclination and 60◦ of abduction Supine positioning resulted in more weight bearing 287

278 in supine position (see Fig. 5). The low tone group in all positions for the children with low and nor- 288

279 showed the highest amount of weight-bearing (93%) mal tone. Children with high tone bore slightly more 289
6 G. Paleg et al. / Inclination, hip abduction, orientation, and tone affect weight-bearing in standing devices

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Fig. 5. Weight-bearing for Participants with High Tone (%±standard deviation (range)).

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Fig. 6. Weight-bearing for Participants with Low Tone (%±standard deviation (range)).
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Fig. 7. Weight-bearing for Participants with Normal Tone (%±standard deviation (range)).
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Fig. 8. Weight-bearing in Supine vs. Prone Orientation.
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Fig. 9. Clinical recommendations.

290 weight in all positions when in prone position (see with normal and low tone behaved similarly in 295

291 Figs. 8 and 9). comparison to those with high tone. As predicted, 296

any amount of inclination or abduction resulted in 297

292 4. Discussion decreased weight bearing for children with high tone, 298

with inclination resulting in a larger difference than 299

293 Tone affected weight-bearing through the feet in abduction. Conversely, maximal abduction resulted 300

294 varied positions in this exploratory study. Children in increased weight-bearing for the group with low 301
 8 G. Paleg et al. / Inclination, hip abduction, orientation, and tone affect weight-bearing in standing devices

302 and normal tone. These results suggest children with 5. Conclusion 351

303 high tone respond differently to the various positions

304 than children with low and normal tone. See Figure In our small study population, angle of inclination, 352

305 for Clinical recommendations hip abduction, and orientation affected weight- 353

306 These results demonstrate that one should avoid bearing through the feet for children in standing 354

307 extremes in positioning (inclination and abduction) devices. Clinicians should be mindful of these fac- 355

308 for children with high tone if weight-bearing is tors when developing a standing program for children 356

309 the main goal of the standing program. For chil- and understand the cost-benefit relationship between 357

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310 dren with high adductor tone, it is possible that postural alignment and weight-bearing in standing 358

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311 increased abduction resulted in increased pressure devices. If the goal is to increase weight-bearing in 359

312 or weight-bearing through the pommel or knee supported standing, it is recommended that children 360

313 supports, although this was not measured. It is with hypertonia be placed in prone upright position- 361

314 unknown if the reduction in weight-bearing through ing with their hips in neutral (feet together) or slight 362

315 the feet that was measured is also accompanied abduction, and children with hypotonia should be 363

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316 by a similar reduction of forces through the aceta- placed in upright supine positioning with a moderate 364

317 bulum. degree of hip abduction. Recommendations for future 365

318 For children with low tone, it may be even more research include scheduling more time for each ses- 366

319 important to measure weight-bearing to ensure it is sion, recording of stander use (e.g., journal of usage) 367

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320 maximized. They have been described as “leaning to record whether weight-bearing changes over time, 368

321 into supports” [17] which may account for the differ- including a larger number of subjects, using only one 369

322 ences. If the children with low tone “hung” or leaned brand of stander, and including whole body pressure 370

323 on the lateral supports and surface of the stander, mapping to document all weight-bearing surfaces. 371

324 particularly in prone position, weight-bearing would

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325 decrease through the feet.
326 The data showed minor differences between the Conflict of interest 372

327 three standers. The standers differed in the amount

328 of contact supports, with the Jenx Standz offering Ginny Paleg received funding for travel to conduct 373

329 a solid posterior support similar to a tilt table. The this study from Prime Engineering. Dr. Paleg is also 374

Zing and HLT Superstand provided smaller sup-

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330 a paid educational consultant for Prime Engineering. 375

331 port surfaces with open space between the supports. She claims no bias in this study. 376
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332 Sit-to-stand devices were not included because a No other authors received funding or have any con- 377

333 previous study concluded that these devices demon- flicts. 378

334 strated the lowest amount of weight bearing [5] All products were provided free of charge from the 379

335 and these models currently do not allow for abduc- manufacturers. 380

336 tion.
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References 381
337 4.1. Limitations
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342 sions. It is possible that different results may have Dev Med Child Neurol. 2013;55(11):1009-15. doi: 10.1111/ 388

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