Can a Passive Standing Program Improve Hip Integrity?

This is a guest post on the EasyStand Blog by Ginny Paleg, DScPT, MS, PT. Ginny is a pediatric Physical Therapist from Silver Spring, MD. She works in a 0-3 (Early Intervention) program for Montgomery County Public Schools.

Children with cerebral palsy most often develop this condition as a result of prematurity. The typical pattern of motor cortex damage follows predictable patterns that result in the distal lower extremity being more involved than the proximal limb. If we agree on this basis principle, then it would follow that the majority of children with CP would have more weakness, tone, spasticity (yes the two are different), tightness and contractures in the ankle versus the hip. And yet, in my experience, many more children are receiving corrective orthopedic surgery on their hips rather than their ankles. How can this be? The anatomy and neuropathology would predict just the opposite. It must then lie with our clinical management. Most children with CP wear ankle foot orthoses (AFO’s) during the day. The newer trend is to wear SMO’s during the day and solid or stretching AFO’s at night along with knee immobilizers and an abduction wedge. Maybe this attention to the ankles, and the relative inattention to the hips has skewed the need for orthopedic surgical correction. Maybe we can do a better job managing the hips. My question today is; Can a passive standing program improve hip integrity?

I suggest that the only way to really know is to look at the evidence. I used many search engines, including googlescholar.com and medline to find as many articles on passive standing and hip integrity as possible. I was disappointed that the number of articles was so small. After I obtained the articles I reviewed them and assigned them a “level” rating based on the Oxford system (see PDF at the end of this blog). This lets me communicate with you how good I thought the article was. You’ll see it’s color coded too. So green means “go” and in this system, it means a gosh darn good article (the best is Level 1 and aqua). Orange, or Level 4 means “eh”. Hey at least there’s an article, but it wasn’t so great.

This is a photo of my impression of the position the children stood in for this study.

What I found were two “eh” or Level 4 articles and one good article. The first one, from Spain, looked at 14 kids with CP. Macias (2005) randomly assigned the subjects to either continue not standing or to stand daily for 45 minutes in a widely abducted spica cast. These kids were 14-17 months old when they began the program and stood this way for 4 years! She measured a bunch of hip stuff before and after and compared these values to the kids that didn’t stand. What she found was amazing! Passive standing really made a difference. The problem here is that it’s very difficult to stand in that much abduction (55-70 degrees). Macias used a custom made spica cast which probably needed to be remade every few months. This is not only costly, but logistically difficult in today’s school-based delivery model. But the point is it really worked!

The second study, from Sweden, was conducted by an orthopedic surgeon. She looked retrospectively (back) through her files to see who developed hip dislocation and subluxation. In the article, Hägglund compared kids who participated in a comprehensive prevention program, and those who did not. Her results are staggering! None of the kids in the prevention program subluxed or dislocated and all of the kids who weren’t in the program did. Now wait a minute – I gotta know more about this magical program! First, the kids were seen twice a year by the PT/OT until they are 6 years old, then once a year after that. At that visit, they took all sorts of standardized measurements and gave standardized tests. Their hips and spine were also assessed and often radiographs (x-rays) were measured. These reports were then sent via the internet to the central clinic for review. As soon as the hips were seen to migrate, they were corrected surgically. Following surgery, the children were given night time positioning programs; specifically an abduction spica cast system which maintained them in knee extension and abduction all night. These children also stood daily in passive standers. Many children also went on for spasticity management including dorsal rhyzotomy and intrathecal bacolfen pumps. But still – 100% with good hips??? So the take home message is probably something like – see your PT/OT, neurologist, physiatrist and orthopedist yearly, fix the hips surgically early and then keep standing and use a nighttime positioning system so the child will never need hip surgery again.

The last study is from the United Kingdom (England) and was conducted at a boarding school for kids with severe disabilities. This team, who has published tons of no-nonsense straight to the point useful articles, noticed that the kids that were managed in appropriate seating, standers and nighttime positioning systems, had less hip problems. It was a retrospective chart review (not a great study design) but the results were really clear – if you only do one or two parts of the program, your hips slip. If you stick to all three, and have your system adjusted often, your hips stay where they are supposed to.

When I look at these three studies, I come out thinking, yes, we can do better. Even if I just do a little more for the hips, it has to help. For my patients (students) this means I try for daily standing beginning at 9 months of age and continuing for life – especially in the 30 year old crowd who had been walking more, but now aren’t. If you or your patient (student) isn’t taking 8,000 steps a day (use a pedometer for a week and see!), you probably could benefit from standing an hour a day. Do my patients (students) stand every day? No. But we try for 3-5x/wk. It’s just like dieting or learning a foreign language, the more you do it, the better results you’ll get. I try to have their seating and wheelchairs adjusted every 6 months (that’s as often as insurance will pay for it!) and slowly I am winning parents, caregivers, nurses, and teachers over to night and nap time positioning. In Europe they are way ahead of us with 24/7 postural management programs – which is probably why all three of these studies come from Europe!

Thanks for reading my blog, and please go now and choose one person for whom you care that does not walk and try, for 3-12 months, to stand 5x/wk for 60 minutes, get their/your chair adjusted every 6 months, and use nighttime positioning. Maybe you can make a difference too. My name is Ginny Paleg and I’m trying to recruit you to using evidence based practice patterns. Feel free to contact me with questions/comments at ginny@paleg.com. If no one emails me I have to clean the house or do the laundry. So please email me or comment on my blog!

Want more fun research on standing? View abstracts for other research studies on standing on the EasyStand website.

Read more blog posts from Ginny Paleg, PT
Can a Standing Program Improve Bowel Function?
Can a Standing Program Improve Motor Skills?