The standing frame is an adaptive piece of equipment commonly prescribed by physical therapists in school settings for children with impaired mobility. Standing frames provide external, adjustable support enabling the child with inadequate postural control to stand. Demonstrations of the effectiveness of the standing frame and specific guidelines for use in the pediatric population have not been fully provided in the scientific literature. Without clinically applicable research, physical therapists must rely on clinical experience to guide their decision making. Consequently, it is hypothesized that among physical therapists in school settings, there is variation in prescription, implementation, and perceived benefits for the use of standing frames by school-age children with impaired mobility.
Pin1 performed a systematic review to examine the research evidence of the effectiveness of static weight-bearing (SWB) exercises in children with cerebral palsy (CP) and identified 10 studies that met her inclusion criteria. Five of these studies focused on the lower extremities. Eight targeted outcomes were identified for the use of SWB exercises in children with CP: improve antigravity muscle strength, prevent hip dislocation, improve bone mineral density, improve self-esteem, improve feeding, improve bowel and urinary functions, reduce spasticity, and improve hand function. Pin used the PEDro scale to score methodological rigor and the “American Academy of Cerebral Palsy and Developmental Medicine evidence table of internal validity” to grade the level of evidence for each selected study. Authors of 2 studies2,3 rated as level I evidence and with high PEDro scores of 6 and 7, reported that SWB exercises are effective for increasing bone mineral density (BMD) in the lumbar spine and femur with clinical significance in reducing susceptibility to fractures. However, Pin concluded that the actual association between increased BMD and decreased incidence of fractures needs to be further studied with an improved methodology for sampling.
The systematic review performed by Pin1 also identified 2 studies4,5 with level I evidence and rigorous methodology with PEDro scores of 6 that addressed the targeted outcome of reducing spasticity. Both of these studies investigated the effect of SWB exercises on spasticity in children with CP and used surface electromyography on ankle muscles to measure changes after 30-minute sessions in a standing frame. Richards et al4 found decreased spasticity of the tibialis anterior and improvement in the initial gait cycle after standing-frame weight-bearing. Tremblay et al5 demonstrated a reduction in resistance in the triceps surae and tibialis anterior muscles with passive stretching for up to 35 minutes after 30 minutes of lower extremity weight-bearing in a standing frame. Pin acknowledged that although these few studies have provided some good evidence that SWB exercises increase BMD in the lumbar spine and femur in children with CP and also temporarily decrease spasticity, the effect size is small and clinical significance remains questionable. Pin determined that evidence is insufficient to support the other targeted outcomes of muscle strengthening, prevention of hip dislocation, and improvement of self-esteem, feeding, and bowel, bladder, or hand function.
In the school setting, standing frames are used for physical health needs such as pressure relief, educational needs such as elevation to access learning materials, and social needs such as promotion of peer interaction. Under part B of the Individuals with Disability Education Act, school physical therapists provide related services to assist a child with a disability to benefit from special education.6 Thus, school physical therapists may need to place greater value on academic and social benefits compared with their colleagues in a medical setting. Financial constraints of school budgets may influence purchase decisions by school physical therapists. The implementation of a standing-frame program may also be limited by availability of support staff in the classroom. The teacher, parent, administrator, and school physical therapist, as members of the individual education plan team, must all agree on the specifics of the standing-frame program. Therefore, it is important to identify the external influences that the school physical therapist may face in the decision-making process regarding standing-frame prescription. The purpose of this study was to determine what variation and what consensus exist among physical therapists in the school setting in the implementation of standing-frame programs. Information on therapist values and priorities is required to direct the design of further outcome studies needed for evidence of best practice.
After a review of the literature, a 20-item survey investigating the use of standing frames in physical therapy practice was developed with school-based physical therapists the target population. The survey contained questions regarding demographics of the respondents, and open- and closed-ended questions that addressed factors relevant to the prescription, implementation, and discontinuation of standing-frame programs (Appendix 1 available online at http://links.lww.com/PPT/A1). Administrative approval was granted by the institutional review board. A pilot survey was mailed to 25 intermediate unit school physical therapists in Pennsylvania, and 14 of these surveys were completed and returned. Final revisions were made based on suggestions to improve content and understanding of survey questions.
Using a random number table, a random sample of 500 APTA pediatric section members who belong to the School-based Special Interest Group was obtained from the member list that was obtained from the APTA’s List Rental Services. The survey with a cover letter and a postage-paid return envelope was mailed to the 500 physical therapists. Return of the completed survey implied consent to participate in this study. A second copy of the survey with a reminder was sent 1 month later to all nonresponders.
Survey data were entered into the Statistical Package for Social Sciences (SPSS) version 15.0 for Windows (SPSS Institute, Chicago, IL). Data were recorded as “missing” when a respondent did not answer a question of the survey.
The response rate after the second mailing was 80.2% with 401 of the 500 surveys returned. Fourteen of the physical therapists reported that they do not practice in school settings, and 1 retired physical therapist returned but did not complete the survey, and, therefore, these surveys were not included in the data analysis. This yielded a usable response rate of 77.2% with a total of 386 surveys. Therapists from 48 states were represented in this study. No surveys were returned by school-based therapists in Hawaii, Delaware, or the District of Columbia. Urban, suburban, and rural settings were all represented.
Table 1 presents the demographics of the survey respondents. The majority of the respondents were women with mean age of 46.6 years and an average of 16.9 years of pediatric practice. Sixty-three percent of respondents worked full time. The highest degree held by 42.5% of respondents was a bachelor’s degree, and, similarly, 42.0% of respondents held a masters degree. The doctorate was the highest degree for 15.5% of respondents. A majority of therapists took continuing education courses, with 14.0% taking 1 course yearly and 83.5% taking more than 1 course yearly. A minority (9.3%) of respondents was reported to be pediatric-certified specialists.
Factors Influencing Standing-Frame Program Prescription
On a 4-point Likert scale, respondents were asked to report the importance of 8 factors that might influence their decision to implement a standing-frame program. Ambulatory status of a child was considered very important by 63.3% of the respondents of this survey (Appendix 2 available online at http://links.lww.com/PPT/A1). Less than 20% of therapists thought that the age of a child and the diagnosis were very important factors in prescribing a standing-frame program. For only a small percentage (11.8%) of respondents, cost or availability of a standing frame was “very important.” Similarly, for only 11.7% of respondents, the ability to use a standing frame with several children was very important. Therefore, the results of this survey did not indicate that a majority of school physical therapists were constrained by cost when implementing a standing-frame program.
Table 2 compares the relative ratings of importance of the 8 factors influencing standing-frame prescription. In comparison with the 7 other factors presented in the survey, ambulatory status received the highest rating of importance with a mean value of 3.49. Severity of physical disability and availability of school personnel were the 2 other factors that received mean ratings of importance >3.0. Severity of cognitive disability received the lowest rating of importance, with a mean rating of 2.11.
Factors Influencing Standing-Frame Selection
On a 4-point Likert scale, respondents were asked to report the importance of 6 factors that might influence their selection of a particular standing frame. A child’s specific needs were considered very important by 85.4% of the respondents of this survey (Appendix 3 available online at http://links.lww.com/PPT/A1). Cost, availability, and previous experience with a particular standing frame were not shown to be of great importance to many therapists. Only a minority of respondents (12.1%) rated the cost of a particular standing frame as very important. Comparatively more therapists (23.5%) rated the availability of a standing frame already in the classroom as a very important consideration. A similar number of therapists (23.4%) rated previous experience with a particular standing frame as very important. More than half of respondents (58.4%) rated ease in transfer as very important in the selection of a particular standing frame. Therapists’ responses were similar in rating the importance of teacher and parent input. Parent input and teacher input were rated as very important by 20.3% of respondents and 21.5%, respectively. Respondents rated parent input and teacher input as important by 52.4% and 59.9%, respectively.
Table 3 compares the relative ratings of importance of the 6 factors influencing standing-frame prescription. Compared with the 6 other factors presented in the survey, a child’s specific needs had the highest rating of importance with a mean value of 3.85. Ease in transfer was also given a comparatively high mean rating of 3.53.
Perceived Benefits of Standing-Frame Program
On a 4-point Likert scale, respondents were asked to report on the importance of 11 perceived benefits of a standing-frame program. All perceived benefits were considered very important or important by more than 50% of responding therapists (Appendix 4 available online at http://links.lww.com/PPT/A1). Improving joint range of motion and soft-tissue flexibility, improving bone strength, promoting self-esteem, promoting social interaction, and providing access to educational materials and activities all were rated as very important or important by 90% or more of all respondents. Pressure relief from sitting was the benefit that most therapists (58.7%) rated as very important. The lowest percentage of therapists (16.2%) rated decreasing spasticity as a very important benefit of a standing-frame program.
Table 4 compares the relative ratings of importance of the 11 perceived benefits of a standing-frame program. Compared with the 10 other possible benefits presented in this survey, pressure relief from sitting received the highest rating of importance with a mean value of 3.52. Table 4 also shows that all perceived benefits received high ratings of importance above 3.0 mean values except muscle strengthening and reduction of spasticity, which received mean values of 2.82 and 2.67, respectively.
Parameters for Standing-Frame Program
Frequency, duration, standing-frame tilt, and the presence of the physical therapist and other school personnel were the parameters of a standing-frame program, which were investigated in this survey, and results are provided in Appendix 5 (available online at http://links.lww.com/PPT/A1). A majority of respondents (67.5%) implemented the standing-frame program once daily. Also, a majority of respondents (58.5%) prescribed 30–45 minutes for the duration of the standing session. Most of the respondents either prescribed a fully upright standing frame (56.7%) or a standing frame tilted supine or prone no more than 20° (35.7%). In the school setting, 96.6% of therapists were not present during implementation of the standing-frame program.
Table 5 provides a ranking of classroom caregivers who were responsible for performing standing-frame transfers. The teacher aide was used most frequently, with a mean response ranking of 1.56 followed by the personal care assistant, with a mean response ranking of 1.86. The classroom teacher less frequently performed the transfer, with a mean response ranking of 2.48, and the physical therapist was given the lowest ranking, with a mean of 3.04.
Decision Making for Discontinuing Standing-Frame Program
In an open-ended question, the therapists responding to this survey were given the opportunity to list their reasons for discharging a student from the standing-frame program. Some type of progression of the orthopedic impairment or decline in medical status was most commonly cited by 208 responses of the 386 responding therapists. With progression of contractures at joints of the lower extremities, therapists reported that adequate alignment could no longer be achieved in a standing frame and therefore the program was discontinued. Poorly fitting ankle- foot orthotics or the unmet need for ankle-foot orthotics were also included in comments regarding progression of orthopedic impairments. In regard to declining medical status, therapists mentioned that orthostatic hypertension, skin breakdown, and lower extremity edema warranted discontinuing the program. Pain, poor tolerance, and/or unacceptable behavior by the student in the standing frame were listed by 142 of the respondents as reasons to discontinue a standing-frame program. One hundred twenty-six therapists also listed logistical factors requiring a standing-frame program to be discontinued, and these included transfers becoming too difficult as the child grew, noncompliance of support staff in carrying out the program, the standing-frame program conflicting with the academic program, storage limitations, and standing frames breaking or being outgrown. A small number of therapists (14 of the 386 respondents) commented that older students moving into middle school or high school did not continue with a standing frame because of social pressures and/or time constraints. Also, 35 respondents reported that a parent’s request led to discontinuing a standing-frame program at school or the standing-frame program was performed at home instead. With improved ambulation and/or improved independent standing ability, 103 of the respondents reported that they would discontinue the standing-frame program.
Factors that influenced the prescription and implementation of standing-frame programs by school physical therapists were investigated in this nationwide survey. A response rate of 77.2% indicates that the topic is of high interest to this subgroup of pediatric therapists. The therapists’ responses indicating that standing frames were used in their practice affirm that this is a commonly used choice of adaptive equipment. The school-based physical therapists responding to this survey had a mean age of 46.6 and were experienced, with a mean of 21.3 years in pediatric practice (Table 1). Fewer of the respondents have doctoral degrees (15.5%), whereas close to equal numbers of respondents have a bachelor’s degree (39.9%) or a master’s degree (39.5%). Given that research provides minimal information on evidence-based practice in regard to standing-frame programs and that respondents were older and experienced, it can be speculated that decision making may be based more on clinical experience than intervention proven to be effective in the scientific literature. Future surveys could include questioning regarding the reliance on clinical experience versus evidence in the scientific literature for determining the best practice.
It was hypothesized that variation exists among school physical therapists in the prescription, implementation, and perceived benefits of a standing-frame program. In the close-ended questions of the survey, all options of the 4-point Likert scale were used by respondents, indicating that variation does exist. However, when calculating the frequency of responses given as “very important” for each item of the survey, consensus was obtained, which can be useful in understanding the current state of practice with standing frames. The majority of responding physical therapists prescribed 30–45 minutes in a standing frame once daily with the frame positioned fully upright (Appendix 5 available online at http://links.lww.com/PPT/A1). The school physical therapist was usually not present during the standing-frame program, and most often the teacher aide or personal care assistant performed the transfer (Appendix 5 available online at http://links.lww.com/PPT/A1; Table 5). For the new school-based physical therapist, this information can provide some preliminary guidelines until further clinical research is able to establish specific protocols. Additional useful information can be provided through consensus on important factors to consider when selecting a standing frame. A physical therapist new to the selection of standing frames will want to consider the child’s specific needs as well as ease in transfers because these were rated most frequently as very important by the respondents in this survey (Appendix 3 available online at http://links.lww.com/PPT/A1).
Physical therapists must justify their recommendations for programming in the school setting to other members of the individual education plan team. The systematic review performed by Pin1 identified studies that provide evidence that weight-bearing programs in standing frames improve BMD and decrease spasticity, whereas there were no studies identified, which provided good evidence for the other perceived benefits listed in this survey. Only a minority of physical therapists responding in this survey rated reduction of spasticity as a very important benefit. A majority of respondents rated pressure relief as a very important factor in prescribing a standing-frame program, yet no published clinical studies have been conducted that demonstrate the reduction of pressure sores with standing-frame programs in the pediatric population. Future research is needed to address the incidence of pressure sores in the presence and absence of supported standing as well as to provide data on optimal frequency and duration of standing-frame use. Such information would allow therapists to justify prescription of what can be a laborious and expensive intervention in the school setting.
Unique to the target group of school-based physical therapists is the consideration of social and educational factors in planning a standing-frame program. Promotion of self-esteem, social interaction, and access to educational materials and activities were rated important or very important by a majority of responding school-based therapists (Appendix 4 available online at http://links.lww.com/PPT/A1). The quantification of these perceived social benefits in future research will aid therapists in promoting the use of standing frames in the school setting.
Results of this survey indicate that school-based physical therapists were not constrained to a great extent by standing-frame costs. Only a minority (12.1%) of respondents rated the cost as very important in the selection of a particular standing frame. To minimize costs, standing frames can be shared among several children in a classroom. However, only 11.7% of respondents rated the ability to share a standing frame with several children as very important when prescribing a standing-frame program.
Physical therapists must consider the amount of tilt of the standing frame when prescribing a program for a particular child. Weight-bearing through the lower extremities is reduced with a lower tilt angle, and the ability to view the classroom environment may also be detrimentally altered. A certain amount of tilt may be required based on the individual child’s status in blood pressure regulation as well as the need to use a reclined position to accommodate decreased head or trunk control. In this survey, a majority of therapists responded that they prescribe a fully upright standing frame, but further research is needed to confirm that this is the best practice. Quantifying the effects of standing-frame tilt on weight-bearing and bone mineralization will guide therapists in program planning.
There were several limitations of this study. Questions for the survey were not developed by an expert panel, and the pilot study was limited in that it was only reviewed by 14 of the 25 school-based intermediate unit physical therapists in Pennsylvania who received the mailing. In an effort to keep the survey questions simple and quick so that response rate would be high, detailed information was not obtained on the type and degree of disability of children receiving standing-frame programs. Also, no questions regarding goal setting were presented, and such questions would be needed to clarify a therapist’s perception of need and purpose for implementing a standing-frame program. Perspective on the importance of a standing-frame program relative to other aspects of a child’s school physical therapy program is lacking. Standing transfers and assisted walking may provide some of the same benefits as the standing frame and may have an effect on decision making for concurrent standing-frame programming. Finally, this survey was limited in that it did not address how therapists specifically use clinical expertise versus evidence-based practice in their implementation of each child’s standing-frame program.
Results of this survey demonstrate that although there is variation in perceived benefits and implementation of standing-frame programs for children with impaired mobility in the school setting, a majority of physical therapists report similarly on certain aspects of this intervention. A majority of school-based physical therapists report that pressure relief, bone strengthening, and enhancement of social and educational opportunities were important benefits of standing-frame use. The survey responses show that a majority of standing-frame sessions were 30–45 minutes in duration and took place daily without the physical therapist present and transfers were performed by classroom or child support staff. Ambulatory status is found to be the most important factor in the decision to prescribe a standing frame for a school child with impaired mobility. The primary influence on the therapist’s selection of a specific standing frame is a child’s specific needs, and ease in transfer is also considered important.
This survey was undertaken to provide descriptive information on how standing frames were currently being used in the school setting by physical therapists. In the absence of clinically applicable research, survey results may prove helpful to new physical therapists beginning to practice in the school setting. This information can also guide researchers in the identification of aspects of standing-frame intervention, which require further investigation for evidence-based practice.
The author extends appreciation to her academic advisor Joy Levine, for providing a critical review of the study proposal and assisting with draft revisions of the manuscript, and to Qiong Wu, for providing data analysis.