R E S E A R C H A R T I C L E

Standing Programs to Promote Hip

Flexibility in Children With Spastic
Diplegic Cerebral Palsy
Lourdes Macias-Merlo, PT, MSc; Caridad Bagur-Calafat, PT, MSc, PhD; Montserrat Girabent-Farrés, MSc, PhD;
Wayne A. Stuberg, PT, PhD, PCS, FAPTA
Physical Therapy Department (Ms Macias-Merlo and Dr Bagur-Calafat), Faculty of Medicine and Health Sciences,
Universitat Internacional de Catalunya, Barcelona, Spain; Early Intervention Public Service of Barcelona (Ms Macias-
Merlo), Barcelona, Spain; Biostatistics Department (Dr Girabent-Farrés), Faculty of Medicine and Health Sciences,
Universitat Internacional de Catalunya, Barcelona, Spain; Physical Therapy and Motion Analysis Laboratory (Dr Stuberg),
Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska.

Purpose: To investigate the effects of a standing program on the range of motion (ROM) of hip abduction
in children with spastic diplegic cerebral palsy. Methods: The participants were 13 children, Gross Motor
Functional Classification System level III, who received physical therapy and a daily standing program using
a custom-fabricated stander from 12 to 14 months of age to the age of 5 years. Hip abduction ROM was
goniometrically assessed at baseline and at 5 years. Results: Baseline hip abduction was 42◦ at baseline and
43◦ at 5 years. Conclusions: This small difference was not clinically significant, but did demonstrate that it was
possible to maintain hip abduction ROM in the spastic adductor muscles of children with cerebral palsy with
a daily standing program during the children’s first 5 years of development. (Pediatr Phys Ther 2015;27:243–
249) Key words: cerebral palsy, cerebral palsy/physiopathology, cerebral palsy/rehabilitation, child, female,
hip joints, human, male, passive range of motion, patient positioning, static passive stretching, treatment
outcome, weight-bearing

INTRODUCTION tion. The ability of muscle to adapt in length is beneficial

Cerebral palsy (CP) describes a group of permanent unless the working range of motion (ROM) is truncated
motor disorders attributed to disturbances that occur in by excessive shortening, as occurs in multiple conditions
the developing brain.1 Although the brain lesion is not that primarily affect muscles of the extremities, includ-
progressive, it results in secondary muscle pathology.2 ing spastic CP. In these conditions, the muscle fibers that
Children with spastic CP often have increased mus- contract at a shortened length are thought to adapt to
cle tone, weakness, decreased flexibility, and muscle the abbreviated working range by decreasing the num-
imbalance.3 During growth, increasing muscle fiber length ber of in-series sarcomeres.4-6 The decrease in ROM in-
is essential for muscle to keep pace with skeletal elonga- volves the soft tissues, including tendons, ligaments, and
joints. The contractures and the changes in the soft tis-
0898-5669/110/2703-0243 sues arise from the muscle being maintained in a shortened
Pediatric Physical Therapy position.6,7 Therapeutic and medical interventions include
Copyright  C 2015 Wolters Kluwer Health, Inc. and Section on

Pediatrics of the American Physical Therapy Association

stretching programs, serial casting, orthotics, tenotomies,
intrathecal baclofen, botulinum toxin, and muscle electri-
Correspondence: Lourdes Macias-Merlo, PT, MSc, C/Maestro Juan Cor- cal stimulation.7,8
rales 83, bajos 1a 08950 Esplugues de Llobregat, Barcelona, Spain The motor ability of children with CP can be classified
([email protected]). into 5 levels using the Gross Motor Functional Classifica-
At the time this article was written, Lourdes Macias-Merlo was a PhD stu- tion System (GMFCS). Children at levels I and II walk
dent in the Physical Therapy Department, Faculty of Medicine and Health
Sciences, Universitat Internacional de Catalunya, Barcelona, Spain. without support, children in GMFCS III are expected to
The authors declare no conflicts of interest. learn to walk with a mobility device, whereas children
DOI: 10.1097/PEP.0000000000000150 in GMFCS IV to V do not usually sit or walk without
support.9 Nordmark et al10 reported that mean ROM of

Pediatric Physical Therapy Standing Programs to Promote Hip Flexibility in Children With Spastic Diplegic CP 243
Copyright © 2015 Wolters Kluwer Health, Inc. and the Section on Pediatrics of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
hip abduction decreases from 43◦ to 34◦ , mainly in early Hip adduction contractures in children with spastic
childhood in those with bilateral spastic CP. The relation- diplegia GMFCS level III decreases the base of support
ship of hip ROM and GMFCS levels shows a more pro- in standing, and the children require assistance to stand
nounced decrease in hip abduction, popliteal angle, and and walk, and demonstrate a scissoring pattern causing
knee extension in children at lower functional levels of problems with foot clearance.4
the GMFCS. A decrease in mean ROM with age may result Therapists who used standers in their supported
in decreased mobility.10 Decreased locomotion has been standing programs reported benefits on weight-bearing,
shown to limit activities of the child and restrict participa- pressure relief, ROM, muscle strength, psychological well-
tion in the community.11-13 being, and other positive effects. The strongest evidence
Stretching is widely used for the treatment and pre- after a standing program was found on hamstring ROM
vention of contractures. The use of muscle stretching is improvements.28 Researchers concluded that standing at
based on the assumptions that stretching will increase least 45 to 60 minutes daily is necessary and 60 minutes is
muscle extensibility, preserve joint ROM for functional optimal to increase hip, knee, and ankle ROM.18,28-32
movement, and prevent or delay the need for orthopedic Most models of standing devices on the market do
surgical interventions.14 However, limited and weak evi- not allow more than 40◦ of combined hip abduction when
dence indicates that manual stretching can increase ROM, the child is standing. For children with adductor spastic-
reduce spasticity, or improve walking efficiency in children ity, this degree of abduction is felt to be insufficient to
with spasticity.15,16 Evidence suggests that the exclusive maintain the extensibility of the hip adductor muscles.33
application of passive stretches is not enough to prevent A standing frame that could be adapted to the individual
muscles from shortening.5 However, stretches combined characteristics of each child and allowing more abduction
with isometric contractions have resulted in significant in- for each leg is desired to promote flexibility of the hip
creases in joint ROM and extensibility.5 According to Fow- adductor musculature and acetabular development.31
less contraction is required in combination with a stretch In 1995, our Public Early Intervention Department
to preserve the number of sarcomeres, and maintain proper initiated a program to manage hip ROM in children with
muscle fiber length.17 spastic CP. This involved children who had not attained in-
In studies of children with spasticity, some evidence dependent walking by 12 to 14 months of age, who demon-
indicates that sustained stretching is preferable to improve strated decreased weight-bearing because of their delayed
ROM and reduce spasticity in joints and muscles, respec- walking skill development, and who showed muscle im-
tively, when compared with manual stretching.15,18 Sus- balance at the hip with a tendency toward increased hip
tained muscle stretch is defined as “holding the targeted adduction in standing or supported walking. This program
joint in the available end range of movement through recruited and followed children with spastic diplegia that
biomechanical means such as standing tables or position evolved to GMFCS level III. This allowed study of the ef-
equipment”15p. 860 for an extended period. Equipment such fects of the standing program to prevent decreasing ROM
as orthoses, splinting, and serial casting can be used as and promote muscle flexibility in the children. We choose
alternatives to sustained stretching.6,15,19,20 Other tech- these children because of the documented hip flexibility
niques, such as positioning, provide a way of administering complications for children with spastic diplegic CP hop-
stretch for extended periods.21 ing they could benefit from this program. The purpose of
Children with spastic diplegic CP commonly have this study was to assess whether standing programs with
muscle shortening and decreased ROM of the lower limb hip abduction would affect hip abduction ROM in children
muscles. Soft tissue abnormalities include muscular im- with spastic diplegic CP with GMFCS level III.
balance between the stronger flexors, adductors and in-
ternal rotators of the hip, and the weaker hip extensors, METHODS
external rotators, and abductors.22 These, combined with
decreased voluntary muscle strength, balance deficits, and Participants
impaired motor control, lead to considerable deteriora- A retrospective cohort of 13 children, 9 boys and 4
tion of functional skills such as walking, standing, sitting, girls, with spastic diplegic CP, at GMFCS level III partici-
and transfers.10 During standing and walking, the adduc- pated in the study. For the calculation of the sample size,
tor muscles and hip flexors tend to adopt a preferential we used a main outcome minimal difference of 4◦ on the
pattern of hip flexion, adduction, and internal rotation, basis of on our pilot work. Thirteen children participated
whereas the abductors, extensors, and external rotators in the study to obtain statistical power of 80% and an alpha
are globally weak, poorly controlled, and finally elongated level of 5%.
as the opposing musculature becomes contracted.23 This Exclusion criteria included previous surgery in the
lower limb walking pattern increases energy expenditure lower limbs, epilepsy, intellectual disability that would not
leading to less efficient walking.24 With growth, the dy- allow the child to fully cooperate with the standing pro-
namic muscle imbalance often results in myostatic con- gram, and perceived difficulty with parental compliance to
tractures in the hip adductors. These contractures can also carry out the standing program with their child. During
be related to progressive changes in the femur and the the study, none of the children received botulinum toxin
acetabulum.10,23,25-27 or surgery in lower extremities.

244 Macias-Merlo et al Pediatric Physical Therapy

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 The intervention consisted of fabricating a standing abduction in the stander was fabricated 10◦ less than max-
frame with hip abduction to be used in their regular phys- imum extensibility of the combined hip adductor muscle
ical therapy program. The children started with the stand- flexibility to ensure tolerance of the stretch. Most standers
ing program at 12 to 14 months of age and continued until were made with approximately 30◦ of abduction of each
they were 5 years of age when the early intervention period leg.
was finished. To fabricate the stander, the child was positioned in
The ethics and research committee at the Universi- the prone position and the feet extended off the table. The
tat Internacional, Barcelona, Spain, approved this study. skin and shoes were covered with plastic wrap (Figure 1).
All parents and/or caregivers gave their written informed The legs were placed in symmetrical hip abduction dur-
consent before their children entered the study. ing fabrication. A goniometer was fixed at the degree of
abduction required to avoid any asymmetry during the
Measurement Protocol fabrication process. Plaster strips were prepared using 8 to
10 layers for each leg, pelvis, and waist. The plaster covered
Before fabrication of the plaster stander, hip abduction
the legs from the waist to just above the heel of the shoes.
ROM was assessed goniometrically using a standardized
Having applied all the bands of plaster, the foot position
protocol.10,34,35 Goniometric measurement was selected as
was adjusted so that the soles of the shoes were horizontal
it is the most commonly used method to assess hip flexibil-
and not oblique to the ground.
ity in children with CP. The protocol included measuring
After drying for 24 hours, the stander was painted
the child in the supine position. Each leg was abducted
with plastic paint. The child’s parents usually participated
separately to the limit of the child’s passive ROM. In this
in the painting of the stander according to the preferences
position, the goniometer was placed with 1 arm parallel
of the child.
to a line connecting the anterior superior iliac spines and
To apply the stander and to adjust it comfortably,
the other arm parallel to the longitudinal axis of the femur.
strips of Velcro were used to stabilize the knees and the
With the pelvis stable, the number of degrees of hip abduc-
pelvis. The parents were informed about how to use the
tion was recorded. A slow stretch of 30 to 45 seconds was
stander at home, and putting a table in front of the child
used to promote relaxation and to promote measurement
while in the stander was recommended. Instruction in-
of the full available ROM. The measurement was taken 3
cluded assurance that the feet were positioned correctly
times by an experienced physical therapist and the average
for symmetrical weight-bearing. The standers were refab-
was recorded.
ricated every 8 to 10 months, depending on the child’s
The first measurements for abduction ROM were
growth.
taken at 12 to 14 months of age. Other measures were
taken when it was necessary to fabricate new standing
equipment or to adjust the standing frame to the ROM of Standing Program
hip abduction for the child.
Overall, children were positioned in their standers for
At 5 years of age, the children ended the early in-
70 to 90 minutes a day, from Monday to Friday. Standing
tervention program and the goniometric measures were
time was split into 2 sessions of 35- to 45-minutes duration
repeated and recorded by the same physical therapist fol-
each. The duration of standing was introduced gradually
lowing the same protocol.
with a minimum of 70 minutes daily. Not to interfere with
family routines, on weekends the prescribed standing time
Fabrication of Standers was 35 minutes per day. Children could play games appro-
The stander for each child was fabricated by the phys- priate to their age and preference while using the stander
ical therapist in the early intervention department. It was (Figure 2). Although all children started to walk with mo-
fabricated with plaster using the child’s body as a mold, bility aids between 30 to 36 months of age, they continued
and included any orthotic used by the child while in the with the standing program until they were 5 years of age,
stander. The child’s hip abduction position determined the to promote hip flexibility.
shape of the stander. The stander controlled the child’s legs To ensure compliance, the physical therapist did
and pelvic position, and placed the pelvis in an appropri- home visits every 4 to 6 weeks to assess and instruct the
ate position avoiding any asymmetry in the frontal plane or parents and other caregivers on how to handle the child’s
excessive lordosis in the sagittal plane. The amount of hip position while using the standing device to ensure the

Fig. 1. Fabrication process of the standing with hip abduction.

Pediatric Physical Therapy Standing Programs to Promote Hip Flexibility in Children With Spastic Diplegic CP 245
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Unauthorized reproduction of this article is prohibited.
 Fig. 2. Frontal, lateral, and posterior view of the standing in abduction.

TABLE 1
Mean, Median, and Standard Deviation of Hip Abduction ROM at
Baseline (14 Months) and 5 Years

ROM N Mean ± SD Median 95% CI

Baseline 13 42.0◦ ± 1.6◦ 42.0◦ 41.0◦ -43.0◦

5y 13 42.8◦ ± 1.6◦ 43.0◦ 41.8◦ -43.8◦

Abbreviations: CI, confidence interval; ROM, range of motion; SD, stan-

dard deviation.

child’s comfort, safety, and appropriate height of the ta-

ble with respect to the height of the child. If parents had
problems following the standing program at home, the
possibility was offered of using it in the nursery school,
Fig. 3. Individual values of hip ROM from baseline (14 month)
with assessment and instruction for the educators.
and 5 years.
All children received physical therapy once a week in
the early intervention service, and no other type of stretch-
ing program was implemented or carried out during this Table 1 shows the 95% confidence intervals at baseline and
period. However, positioning for sitting was monitored. at 5 years. Although the variability in the ROM is slightly
higher at 5 years, we have the same values at baseline (95%
confidence interval = 41.0, 43.0) and at 5 years (confidence
Data Analysis interval = 41.8, 43.8). Figure 3 shows the individual ROM
Statistical data analysis was performed using the sta- values at baseline (14 months) and at 5 years.
tistical package SPSS 18.00. The Mann-Whitney U test, a
nonparametric statistic, was used to assess the differences
DISCUSSION
in hip measures because of the small sample size and the
fact that the distribution was not normally distributed. The main results of this study show that hip abduction
The alpha level was set at .05. The mean and median val- ROM can be maintained over a period of 4 years with a daily
ues, and 95% confidence interval of hip abduction ROM, standing program.
were calculated at the beginning of the standing program, The results of this research support the findings of
when children were on average 14 months of age, and at Gibson et al,28 Martinsson and Himmelmann,31 Salem
5 years of age. et al,18 and Paleg et al,32 which show that muscle flexibility
can be maintained through the use of a sustained stretch-
ing program. According to a recent systematic review by
RESULTS Paleg et al32 on recommendations for pediatric standing
A significant difference between hip abduction ROM programs, the use of standing devices seems to have pos-
at baseline (14 month) and at the end of the standing itive effects on lower-extremity ROM, hip biomechanics,
program (5 years) was found (Table 1), using the non- and spasticity.
parametric test. The results of this study are in agreement with studies
All children increased or maintained hip abduction where the hip adductor muscles are placed in a length-
ROM during the standing program up to age 5 years. ened position through standing in abduction.30,31 Other

246 Macias-Merlo et al Pediatric Physical Therapy

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authors have provided support for the use of prolonged We are evaluating the radiologic findings with the same
stretch through the use of a night-time hip abduction po- study group that is the subject of this report, and pre-
sitioning system.36 According to the study by Martinsson liminary results suggest that the migration percentage of
and Himmelmann,31 weight-bearing with 60◦ of total hip these children remained within stable limits at 5 years
abduction and 0◦ of hip extension for at least 1 hour per of age.
day reduced hip migration percentage and preserved ROM. Although an actual increase in ROM was not seen in
However, we think that the use of the standing program the study, the lack of development and progression of con-
twice a day for at least 45 minutes is better than once a day. tracture is the significant finding of this research. Although
For young children, combining activity with the standing all children learned to walk with mobility aids before the
program is more enjoyable and therefore the program is age of 5 years, we decided to continue to use the standing
better tolerated. program to help maintain hip adductor flexibility because
Although all children in the study started to walk with the decrease in ROM is greatest early in life.10 Maintain-
mobility aids between 30 and 36 months of age, they con- ing the flexibility of hip adductors in the first years of life
tinued with the standing program until they were 5 years can prevent a narrow base of support and increase walking
of age, to promote hip flexibility. Because spastic muscles speed during walking, important goals for children with
cannot grow in accordance with skeletal growth,20 finding CP who are at GMFCS level III and partially ambulatory.30
ways to intervene in early childhood is crucial to maxi- None of the children in this study required surgical
mize a physiological balance in growth between muscles intervention for any leg muscles as no progression in hip
and bones. contracture was seen. Although the results of this study
Daily periods of stretching through standing and dur- show a statistically significant difference in hip abduction
ing the child’s daily routines can help in maintaining the ROM at 5 years, we cannot say that the increase the ROM
ROM, as shown in the results of this study. was clinically significant because the magnitude was small.
To ensure compliance with the program, visiting the However, the adductor muscles did not lose ROM with
families’ homes every 4 to 6 weeks and the child’s nursery age, which is common in children with spastic diplegic
school is necessary. During every weekly session, parents CP.10,38 The longitudinal data published by Nordmark
reported feedback if they had problems to ensure compli- et al10 show that for measurements such as hip abduc-
ance rates, the child’s tolerance, and the games they played tion and the popliteal angle, there can be a considerable
during the regular routine while standing. Parents reported change during the early years, with the mean ROM of hip
less scissoring of the legs following use of the stander, and abduction decreasing from 43◦ to 34◦ , between age 2 and
this was very encouraging for them. Perhaps this leads to 14 years. McDowell et al38 found significant reductions in
consistency for the parents and removes the need for use passive ROM for the hamstrings and hip adductor mus-
traditional stretching techniques that can be a burden be- culature in children with spastic CP. The mean of hip
cause of the number of other interventions their child may abduction in children of 4 to 10 years at GMFCS level III
require. With time the ability to take steps without the feet was 25.9◦ ± 9.5◦ .38 These children also had no history of
crossing the midline was another reason to encourage the lower limb surgery.
parent’s compliance. Another benefit of using a custom standing frame is
Standing with the legs in the elongated position with that plaster is a cheaper material allowing for less cost with
the trunk in a symmetric and stable position, children the changes in the cast that were needed while the child
played comfortably and were using the trunk and arm grows in comparison to the cost of changing commercially
muscles, which may have also resulted in activating the available standers.
leg muscles in the extended position and could have con- Although standing devices seem to improve body
tributed to the results. functions and structure, they also promote participation
At 5 years of age, all children were again classified in upright activities, allowing the child to be at eye level
at GMFCS level III because they could not walk 100 me- with peers.32
ters without a mobility aid. However, 4 could walk short A limitation of this study is the lack of established re-
distances indoors without mobility aids and 6 could walk liability of the goniometric measures. This limitation was
at home and over flat surfaces with 1 crutch. All of them minimized by use of a standardized protocol and also hav-
walked with mobility aids outdoors (posterior walkers or ing the same experienced tester performing all measure-
crutches). None crossed their feet during walking, show- ments without knowing the baseline measures. On average
ing more flexibility in their mobility, and running games 3 standings frames were made for each child due to growth
with their peers. and the measures of abduction did not differ from the mea-
According Harris and colleagues37 good evidence surement made at 5 years. Although this does not remove
shows that if the hip is centered before the age of 4 years, bias, it does help to ensure consistency of the measure-
subsequent acetabular dysplasia and hip dislocation is less ments. Despite the disadvantages of goniometric measure-
likely. Other authors reported that postural management of ments such as low reliability, they are the most commonly
children with CP when using equipment could maintain used clinical measure and easily applied to assess muscle
muscle length and joint range of movement to promote shortening, usually in children with spasticity.35,39 The
acetabular growth and to prevent hip subluxation.21,28,36 fact that children did not cross their feet during walking at

Pediatric Physical Therapy Standing Programs to Promote Hip Flexibility in Children With Spastic Diplegic CP 247
Copyright © 2015 Wolters Kluwer Health, Inc. and the Section on Pediatrics of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
5 years of age also justifies maintaining ROM and flexibility 8. Lieber RL, Steinman S, Barash IA, Chambers H. Structural and
of the adductor muscles. functional changes in spastic skeletal muscle. Muscle Nerve.
2004;29(5):615-627.
Other limitations of this study include a lack of a 9. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi
control group, and the small number of children. Further B. Development and reliability of a system to classify gross mo-
research is necessary with larger sample sizes to replicate tor function in children with cerebral palsy. Dev Med Child Neurol.
these findings. However, the findings provide new insights 1997;39(4):214-223.
into the management of children with spastic diplegic CP 10. Nordmark E, Hagglund G, Lauge-Pedersen H, Wagner P, Westbom
L. Development of lower limb range of motion from early childhood
through the use of a sustained standing program. This is to adolescence in cerebral palsy: a population-based study. BMC Med.
the first study that demonstrates that sustained stretch of 2009;7:65.
the adductors muscles has maintained their ROM and pro- 11. Bottos M, Gericke C. Ambulatory capacity in cerebral palsy: prognos-
motes muscle flexibility using a daily standing frame in tic criteria and consequences for intervention. Dev Med Child Neurol.
adduction across 4 years. Because of the lack of a control 2003;45(11):786-790.
12. Jahnsen R, Villien L, Egeland T, Stanghelle JK, Holm I. Locomotion
group, we cannot assume a causal relationship between use skills in adults with cerebral palsy. Clin Rehabil. 2004;18(3):309-316.
of the stander and maintenance in hip abduction ROM. At 13. Tieman B, Palisano RJ, Gracely EJ, Rosenbaum PL. Variability
4 years of age, children had preserved ROM of hip adduc- in mobility of children with cerebral palsy. Pediatr Phys Ther.
tors; and at 5 years of age they were able to take steps with 2007;19(3):180-187.
foot clearance, without having received botulinum toxin 14. Wiart L, Darrah J, Kembhavi G. Stretching with children with cerebral
palsy: what do we know and where are we going? Pediatr Phys Ther.
while still maintaining muscle flexibility of the hip adduc- 2008;20(2):173-178.
tors. It could be recommended that this study be replicated 15. Pin T, Dyke P, Chan M. The effectiveness of passive stretching in
for children at GMFCS level IV. children with cerebral palsy. Dev Med Child Neurol. 2006;48(10):855-
Future studies might also address the combined 862.
effects of a standing program in abduction, which causes 16. Katalinic OM, Harvey LA, Herbert RD, Moseley AM, Lannin NA,
Schurr K. Stretch for the treatment and prevention of contractures.
an isometric muscle contraction of hip adductors through Cochrane Database Syst Rev. 2010;9:CD007455.
passive static stretch, with exercises that generate active 17. Fowles JR, Sale DG, MacDougall JD. Reduced strength after pas-
contractions of the same muscles.5 sive stretch of the human plantarflexors. J Appl Physiol (1985).
2000;89(3):1179-1188.
18. Salem Y, Lovelace-Chandler V, Zabel RJ, McMillan AG. Effects of
prolonged standing on gait in children with spastic cerebral palsy.
CONCLUSIONS Phys Occup Ther Pediatr. 2010;30(1):54-65.
The results of this study indicate that children with 19. O’Dwyer N, Neilson P, Nash J. Reduction of spasticity in cerebral
spastic diplegic CP, GMFCS level III, who use a standing palsy using feedback of the tonic stretch reflex: a controlled study.
Dev Med Child Neurol. 1994;36(9):770-786.
program with hips in abduction maintained the flexibility 20. Tardieu C, Tardieu G, Colbeau-Justin P, Huet de la Tour E, Lespargot
of their adductor muscles. Because the number of children A. Trophic muscle regulation in children with congenital cerebral
in this study was small, these results have to be interpreted lesions. J Neurol Sci. 1979;42(3):357-364.
with caution and cannot be generalized to the larger pop- 21. Pountney TE, Mandy A, Green E, Gard PR. Hip subluxation and
ulation of children with spastic diplegia. dislocation in cerebral palsy - a prospective study on the effec-
tiveness of postural management programmes. Physiother Res Int.
2009;14(2):116-127.
22. Lespargot A, Renaudin E, Khouri N, Robert M. Extensibility of hip
REFERENCES adductors in children with cerebral palsy. Dev Med Child Neurol.
1994;36(11):980-988.
1. Rosenbaum P, Paneth N, Leviton A, et al. A report: the definition
23. Flynn JM, Miller F. Management of hip disorders in patients with
and classification of cerebral palsy April 2006. Dev Med Child Neurol
cerebral palsy. J Am Acad Orthop Surg. 2002;10(3):198-209.
Suppl. 2007;109:8-14.
24. Gage J, Schwartz M, Koop S, Novacheck T. The Identification and
2. Gough M, Shortland AP. Could muscle deformity in children
Treatment of Gait Problems in Cerebral Palsy. 2nd ed. London: Mac
with spastic cerebral palsy be related to an impairment of muscle
Keith Press; 2009.
growth and altered adaptation? Dev Med Child Neurol. 2012;54(6):
25. Bleck EE. The hip in cerebral palsy. Orthop Clin North Am.
495-499.
1980;11(1):79-104.
3. Himmelmann K, Beckung E, Hagberg G, Uvebrant P. Gross and fine
26. Dietz V, Berger W. Normal and impaired regulation of muscle stiff-
motor function and accompanying impairments in cerebral palsy.
ness in gait: a new hypothesis about muscle hypertonia. Exp Neurol.
Dev Med Child Neurol. 2006;48(6):417-423.
1983;79(3):680-687.
4. Wren TA, Rethlefsen S, Kay RM. Prevalence of specific gait abnor-
27. Hufschmidt A, Mauritz KH. Chronic transformation of muscle in
malities in children with cerebral palsy: influence of cerebral palsy
spasticity: a peripheral contribution to increased tone. J Neurol Neu-
subtype, age, and previous surgery. J Pediatr Orthop. 2005;25(1):
rosurg Psychiatry. 1985;48(7):676-685.
79-83.
28. Gibson SK, Sprod JA, Maher CA. The use of standing frames for
5. Van Dyke JM, Bain JL, Riley DA. Preserving sarcomere num-
contracture management for nonmobile children with cerebral palsy.
ber after tenotomy requires stretch and contraction. Muscle Nerve.
Int J Rehabil Res. 2009;32(4):316-323.
2012;45(3):367-375.
29. Lourdes M, Joaquin F. Fisioterapia en Pediatria. España: McGraw Hill
6. Tardieu C, Huet de la Tour E, Bret MD, Tardieu G. Muscle hypoexten-
Interamericana; 2002.
sibility in children with cerebral palsy: I. Clinical and experimental
30. Macias L. The effect of the standing programs with abduction on
observations. Arch Phys Med Rehabil. 1982;63(3):97-102.
children with spastic diplegia. Pediatr Phys Ther. 2005;17(1):96.
7. Pirpiris M, Grraham K. In: Barnes MP, Johnson GR, eds. Management
31. Martinsson C, Himmelmann K. Effect of weight-bearing in abduction
of Spasticity in Children. Upper Motor Neurone Syndrome and Spasticity.
and extension on hip stability in children with cerebral palsy. Pediatr
Cambridge University; 2001:79.
Phys Ther. 2011;23(2):150-157.

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Unauthorized reproduction of this article is prohibited.
32. Paleg GS, Smith BA, Glickman LB. Systematic review and 36. Hankinson J, Morton RE. Use of a lying hip abduction system in
evidence-based clinical recommendations for dosing of pediatric children with bilateral cerebral palsy: a pilot study. Dev Med Child
supported standing programs. Pediatr Phys Ther. 2013;25(3): Neurol. 2002;44(3):177-180.
232-247. 37. Harris NH, Lloyd-Roberts GC, Gallien R. Acetabular development
33. Le Metayer M. Reeducation Cerebro-motrice du Jeune Enfant, Education in congenital dislocation of the hip. With special reference to the
Thérapeutique. Masson ed. Parı́s; 1993. indications for acetabuloplasty and pelvic or femoral realignment
34. McDowell BC, Hewitt V, Nurse A, Weston T, Baker R. The variability osteotomy. J Bone Joint Surg Br. 1975;57(1):46-52.
of goniometric measurements in ambulatory children with spastic 38. McDowell BC, Salazar-Torres JJ, Kerr C, Cosgrove AP. Passive range
cerebral palsy. Gait Posture. 2000;12(2):114-121. of motion in a population-based sample of children with spastic cere-
35. Stuberg WA, Fuchs RH, Miedaner JA. Reliability of goniometric mea- bral palsy who walk. Phys Occup Ther Pediatr. 2012;32(2):139-150.
surements of children with cerebral palsy. Dev Med Child Neurol. 39. Harris SR, Smith LH, Krukowski L. Goniometric reliability for a child
1988;30(5):657-666. with spastic quadriplegia. J Pediatr Orthop. 1985;5(3):348-351.

CLINICAL BOTTOM LINE

Commentary on: “Standing Programs to Promote Hip Flexibility in Children With Spastic Diplegic Cerebral
Palsy”

“How could I apply this information?”

Although children with cerebral palsy Gross Motor Function Classification System level III typically walk,
they often have spasticity and hip problems that affect walking. The results of this study support prolonged
daily standing with the hips abducted as effective in maintaining hip abduction range of motion (ROM). Manual
stretching programs have not demonstrated this effect. Fabrication of a small, customized stander like the one
used in this study is a good alternative to manufactured standers.
Parent response: I feel like I’m not alone! My 5-year-old son participates in a home standing program to avoid
hip surgery and maintain his ability to stand and walk. It is a lot of work, but other children with cerebral palsy
could find success following this type of program. The nice thing about this study is that it divided the daily
standing into 2 shorter time bouts, instead of 1 long session, which makes it more manageable for parents.
“What should I be mindful about when applying this information?”
The results may not generalize to other Gross Motor Function Classification System levels or ages. The plaster
standers used were set at 10◦ less than maximum hip abduction range; thus, the results of maintained ROM
instead of increased ROM would be expected. Appropriate frequency, intensity, and duration of standing are
necessary for positive outcomes, and, consequently, adherence with the home protocol is important. Additional
physical therapy was provided once weekly. Although details of that intervention were not included, the dosage
was low and unlikely to have had an effect on ROM. Applying the plaster cast while maintaining leg symmetry is
challenging and may result in less than optimal positioning. Therefore, keeping the child entertained and using 2
therapists during fabrication may help this process.
Parent response: A home standing program sounds like an easy thing to do, but it is not! The reality is that
children are not always cooperative. It is difficult to get them to stretch for an extended period of time. I need to
keep my son extremely distracted and constantly engaged in a fun activity when standing or he makes it known that
he “wants out.” Kids need to be kids during exercise and incorporating play is important. It may have been helpful
for the researchers to take a parent survey of how the children reacted or complied during the home programs.

Nicole Bishop, PT, DPT

California Children’s Services, County of Los Angeles
Santa Clarita, California
Beth A. Smith, PT, DPT, PhD
University of Southern California
Los Angeles, California
Norma Prieto
Mother of a boy with cerebral palsy
Newhall, California
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0000000000000155

Pediatric Physical Therapy Standing Programs to Promote Hip Flexibility in Children With Spastic Diplegic CP 249
Copyright © 2015 Wolters Kluwer Health, Inc. and the Section on Pediatrics of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.