Using Trunk Supports to Improve Trunk Control on Rifton Standing Frames

Most infants are born with normally functioning musculoskeletal systems and grow up oblivious to the complex processes required to lift a fork to their mouth, roll over in bed, or stroll through the park. The brain signals muscles to move, and healthy bones and joints function reliably. However, an infant or child with a condition such as prematurity, genetic differences, or brain injury may experience dysfunctional neuromuscular transmission, which eventually can impact this child’s bone and joint development.

When muscles move in unusual patterns (abnormal tone) or don’t move frequently enough, they tend to get tight (develop contractures).¹ Since infants’ bones are soft and not fully formed, the presence – or absence – of mechanical tension from muscle contractions can affect how the skeletal system is formed. Growing up with complex medical conditions may result in a greater risk for scoliosis (curvature of the spine), hip dysplasia (unstable hips that become flattened and painful) and decreased bone density (fragile bones).^2,3 Often these changes occur so gradually that they can be missed unless caregivers and medical professionals are anticipating and proactively working to prevent them.

Most caregivers understand and recognize when their child doesn’t “look straight,” but they may not be aware that some positions are more important than others to protect their child’s body shape. For example:

1. Hip-healthy positioning is essential for every infant to safeguard their developing hip sockets. There is evidence of hip dypslasia in nearly 15% of all newborns.⁴ In these instances, clinicians recommend placing the infant’s legs in an open (abducted) position to better seat the ball of the leg bone (femoral head) deep within the socket of the hip (acetabulum). This helps the joint to become round and stable. A typically growing toddler will naturally start standing and walking in the abducted hip position for more stability. By the same token, children who require support to stand also benefit from adaptive standers that can be positioned in hip abduction to minimize the risk of hip dysplasia.^5,6,7
2. Proper spinal alignment begins with a level and stable pelvis. The pelvis is the foundation (base of support) for the spine and head. If it is not level when a child is sitting or standing, the spinal column will tend to lean toward the lower side of the pelvis, and then compensate back toward the opposite side, in an effort to keep the head more centrally positioned over the body.^7,8 Adaptive standers with independent leg and foot supports allow for precise adjustments to accommodate leg length discrepancies or muscle tightness, ensuring the pelvis remains level and correctly aligned.
3. Upright and balanced head positioning is also important for daily life, from eating and socializing to simply observing the world. Imagine the head as a 5-7 lb bowling ball (the average weight for a five-year-old) supported on the end of a spring (the neck). If the head tilts, it creates a pull on the neck and spine. The further it moves off-center, the more gravity takes over, making it hard to return to neutral. Conversely, when the spine is properly aligned and the head sits squarely on top, it becomes significantly easier to maintain an upright head and trunk.⁹
4. Upright and more active standing improves bone density by facilitating full weight bearing through the legs and feet. For optimal comfort and function, the hips, knees, and ankles should be held in straight alignment to mimic a natural posture. While ankle-foot orthoses provide stability from the ground up, adaptive standers ensure the entire lower body remains properly aligned for children who cannot stand independently. Regular use of standers promotes increased bone density, leading to a stronger, healthier skeletal system.¹⁰

Successful, consistent use of adaptive standers relies on a partnership between caregivers, therapists, teachers, and children. Involving caregivers in the initial fitting empowers them to make future adjustments as the child grows, or as their range of motion or alignment evolves. Caregivers can:

1. Assist the clinician during their child’s mat evaluation by helping their child remain relaxed and feel secure. This will ensure a more accurate assessment of the child’s limbs and joint range before the stander is adjusted.
1. Observe where the child requires support while lying down to achieve a straighter posture. Taking photos can help guide later placement of lateral supports at the chest and hips.
2. Use lateral (side-view) photos and a mobile app (such as Angle Meter 360)^11,12 to premeasure joint angles at the hips, knees and ankles for optimal alignment and comfort.
2. Measure each body segment (heel to knee, knee to hip, pelvis to underarm, shoulder to top of head) to preset the stander dimensions before transfer.
3. Make adjustments starting from the base of support and moving upwards. Establish the pelvis first, then the lower extremities and feet, followed by the chest, shoulders and head.
4. Refer back to the photos taken during the mat evaluation to confirm that the child has achieved their optimal position after setup.
1. Stand back and visualize an imaginary line descending from the head to the pelvis. Is the child centered?
2. Are the lateral supports at the hips keeping the pelvis level and forward facing?
3. Are the straps, harness and lateral supports at the chest positioned to reduce any rotation or shift to the sides?
4. Adjustments should mimic the corrective pressure your hands would provide to achieve symmetrical vertical alignment.

Caregivers can gradually prompt more active trunk and head control through fun activities that require reaching above shoulder level or to the sides. Examples include playing with a balloon suspended on a string at eye level, rolling and corraling a ball on the tray, or reaching for bubbles in different planes. Beyond physical benefits, regular use of a stander often yields improvements in social skills, oral motor control, communication, vision, and hand-eye coordination.¹³

As active control improves, lateral supports at the trunk can be lowered, and chest straps may be loosened or released to allow for greater upper body control and movement. The overall angle of the stander can be adjusted relative to gravity, to increase or reduce challenge as clinically indicated. Adjustments should not compromise alignment and stability and can be done for short periods as tolerated. If the child shows signs of fatigue, they should be repositioned with more support. In time, the head support of a supine stander may be temporarily removed, as the child’s head or upper trunk control improves. Similarly, a child may begin to tolerate prone stander positioning without head support. These gains often transfer to other positions, resulting in better head control during sitting or during tummy time.

References:

1. Cloodt E, et al. Knee and foot contracture occur earliest in children with cerebral palsy: a longitudinal analysis of 2,693 children. Acta Orthop. 2020;92(2):222-227. doi:10.1080/17453674.2020.1848154
2. Hägglund G, et al. Incidence of scoliosis in cerebral palsy. Acta Orthop. 2018;89(4):443-447. doi:10.1080/17453674.2018.1450091
3. Krarup LH, et al. Hip displacements and correctable scoliosis were prevalent in children with cerebral palsy registered in a Danish follow-up programme from 2010 to 2020. Acta Paediatr. 2024;113(2):336-343.
4. International Hip Dysplasia Institute. International Hip Dysplasia Institute website. Accessed April 7, 2026. https://hipdysplasia.org/
5. Presedo A, Rutz E, Howard JJ, Shrader MW, Miller F. The etiology of neuromuscular hip dysplasia and implications for management: a narrative review. Children (Basel). 2024;11(7):844. doi:10.3390/children11070844
6. Paleg G, Livingstone R. Evidence-informed clinical perspectives on postural management for hip health in children and adults with non-ambulant cerebral palsy. J Pediatr Rehabil Med. 2022;15(1):39-48. doi:10.3233/PRM-220002
7. Hägglund G. Association between pelvic obliquity and scoliosis, hip displacement and asymmetric hip abduction in children with cerebral palsy: a cross-sectional registry study. BMC Musculoskelet Disord. 2020;21(1):464.
8. Casey J, et al. Incidence and sequence of scoliosis and windswept hip deformity: which comes first in 4148 children with cerebral palsy? A longitudinal cohort study. BMC Musculoskelet Disord. 2024;25(1):222.
9. Saavedra S, et al. Segmental contributions to trunk control in children with moderate-to-severe cerebral palsy. Arch Phys Med Rehabil. 2015;96(6):1088-1097. doi:10.1016/j.apmr.2015.01.016
10. Paleg GS, Smith BA, Glickman LB. Systematic review and evidence-based clinical recommendations for dosing of pediatric supported standing programs. Pediatr Phys Ther. 2013;25(3):232-247. doi:10.1097/PEP.0b013e318299d5e7
11. Kozlov A. Angle Meter 360. App Store. Accessed April 7, 2026. https://apps.apple.com/us/app/angle-meter-360/id1393860479
12. Kozlov AV. Angle Meter 360. Google Play Store. Accessed April 7, 2026. https://play.google.com/store/apps/details?id=com.alekseykozlov.AngleMeter&pli=1
13. Paleg GS, Williams SA, Livingstone RW. Supported standing and supported stepping devices for children with non-ambulant cerebral palsy: an interdependence and F-words focus. Int J Environ Res Public Health. 2024;21(6):669. doi:10.3390/ijerph21060669