Prolonged immobility in a sitting or lying position can result in contractures, skeletal deformity, skin ulcers, and digestion, respiration, or circulatory system deficits for special needs children. However, independent standing requires the ability to extend the hips and knees, and bear weight to hold the body upright against gravity.
The different types of joints in the body require different amounts of muscle control. The knee, a hinge joint, moves in essentially two directions: flexion (bend) and extension (straighten.) The hamstring muscles behind the thigh bend the knee, and the quadriceps muscles in front of the thigh straighten the knee. With the foot fixed in place, any movement at the knee is controlled by simultaneous contraction of both these muscle groups as well as others to stabilize the knee. The same is true at the hip, which is a ball and socket joint that can move in many directions. All the directional movement at the hip means that a lot of muscle control is required. No wonder children with motor delays often have the most difficulty controlling their hips. Also, hips are often the joints where deformity first occurs. A child whose leg muscles are weak at these joints, or who has difficult issues of spasticity and tone, cannot hold their body up against gravity.
A child who cannot stand up against gravity, spends a lot of time in a wheelchair or in adaptive seating, or on a loveseat or beanbag. Because their hips and knees are bent while they sit, they develop tight hip flexor muscles and tight hamstring muscles. When you never open up these joints in a standing position, over time they reach the point of being unable to fully straighten out. Yet with proper alignment in standing, gravity (which is always present) is known to positively affect bone and muscle development as well as promote proper functioning of internal organs.
For this reason it is important to give a child plenty of opportunity to be in a standing position, starting at an early age before the contractures develop. Then the full range of motion can be maintained. The design of the human body is such that when these joints of the leg can fully straighten, it actually takes less effort for the muscles to stand and walk. When contractures are present, it is much more challenging for the muscles to try to maintain a standing posture or forward walking momentum – the opposing muscle groups have to be activated against the force of gravity and there is much more effort required. You will find this yourself if you try to walk for a long distance in a slightly crouched position. Another muscle group where there may be high tone, spasticity, and resulting contracture is the calf muscles, resulting in difficulty for the child’s ankle to get to a neutral position. With ankle-foot-orthoses, contractures can be avoided. An upright standing position is also an ideal way to obtain a natural stretch for the calf muscles.
Features of the Rifton Prone Stander
The prone stander is used by children able to maintain head control with their anterior trunk supported and their arms placed forward on the tray. The prone stander supports the child from the front of the body; the user is in a forward leaning position and can easily view their activity and surroundings, thus further developing their neck and upper trunk extensor muscles for postural control. This easy-to-use stander has accessory options to hold the feet, knees, buttocks and trunk in place.
The Rifton Prone Stander is available in three sizes (Figure 1). Each prone stander comes with a comfortable body pad on the trunk board, a pair of trunk lateral support blocks, a hip strap, and a footboard. The body pad and lateral support blocks are easily removed for cleaning. The curved S-frame comes in two color options and gives plenty of room for the caregiver to stand close by to work with the child. Double-locking casters prevent roll and swivel during transfers. The trunk board can be raised and lowered relative to the footboard, to provide varying amount of support (in height). Additionally, each accessory described in this article, as well as the footboard, are height adjustable, so that this stander can quickly and easily accommodate variations in trunk and leg height between users, and be adjusted to provide decreasing support as the user's motor control increases.
Further adjustable accessories for all prone standers include sandals with straps, wedges for the sandals, knee lateral support blocks and hip abduction and hip stabilizer accessories, as well as additional hip strap and trunk lateral support blocks. These supports can be simply positioned at any height as needed, to secure the child’s trunk and provide appropriate hip extension and lower extremity alignment. The stander can be positioned in any angle from horizontal to 85° (near vertical) and the angle indicator at the pivot point can be used to document the position. When upright, the footboard is almost floor-level, making transfers easy.
The small prone stander can be used for children from 25 inches tall to 48 inches tall. The kneeboard can be removed easily, and the footboard raised, to accommodate the smallest child, and provide a cost-effective solution for the child’s continuing growth. (Figure 2) The small prone stander has a unique double-strap hip strap to provide secure support to the trunk in standing. The round abductor with hip stabilizer is a further option for hip extension stabilization for the small prone stander. (Figure 3) Or, without the hip stabilizer, the round abductor is available to this model for lower extremity positioning.
The medium prone stander accommodates children from 44 inches to 59 inches tall. This stander comes with the wide and comfortable hip strap, and has the options of the round abductor or the abduction wedge for lower extremity positioning, with or without the hip stabilizer as needed. The large prone stander serves children from 57 inches to 72 inches in height, and also has the options of the round abductor or the abduction wedge for lower extremity positioning. The adjustable abduction wedge can be changed from 3½" – 11" in width, depending on how much abduction is desired. For the large prone stander, the hip stabilizer option comes with the adjustable abduction wedge only.
- The spacious tray adjusts at various angles and gives space for a communication device or tray activities.
- Trunk Lateral Support Blocks are positioned anywhere along the board, at any angle up to 30°.
- Knee Lateral Support Blocks adjust easily, to slide up and down, or rotate.
- The Hip Strap gives secure comfortable security at the trunk or hip, and is easy to adjust in position and width. An additional wide strap can be ordered as needed.
- The Round Abduction block, for all three models, is 4 inches in diameter. Add 2 more inches of abduction with the addition of the Collar.
- The Hip Stabilizer maintains hip extension. The stabilizing pad can be adjusted in depth and height position. It is attached with the Round Abduction block for the Small and Medium standers, and is attached with the adjustable Abduction Wedge for the Medium and Large standers.
- The Adjustable Abduction Wedge can be simply changed from a narrow 3½ inches of abduction to a wide 11 inches of abduction as needed. (Figure 4)
- Sandals and Wedges secure the feet, and can be configured to raise heels or toes or accommodate leg lengths.
For further information on accessory attachment and configuration, refer to the Product Manual available on the Rifton website. For further iIllustrations, refer to Prone Stander Accessories on the Rifton website.
Therapeutic Positioning and the Benefits of Standing
To maintain a standing position, knee extension and hip extension are required. Equipment can provide the necessary support and external control to provide an opportunity to stand.
Therapeutic positioning is the use of adaptive equipment for postural placement of the body with alignment and stabilization, to help normalize muscle tone and for meaningful participation in activity. Therapeutic positioning should not be viewed as an end in itself; rather, the purpose is to enable the child to perform functional activities. Proper positioning is not only essential for healthy physical development but can also be instrumental for effective instruction of students with multiple physical disabilities.
Providing too much support for postural positioning can be detrimental, because special needs children will often rely on whatever support they are given rather than using their own motor skills, and so can eventually lose rather than gain abilities. Too much external control also limits opportunities for the child to develop their own internal control by improving their motor skills. Too little control, however, can result in failure to assure an aligned upright posture, allowing possible deformity or hampering participation in activity.
When positioning children, each child is viewed as a unique individual. The more customized the support can be, the better. An accessory or support that is necessary or effective for one child may be unnecessary or ineffective for another. Positioning equipment should be seen as a therapeutic tool that is implemented and used thoughtfully. Thus, it is important to understand the adjustability of the equipment. In this way, support can be changed as the child’s skill level changes and improves, or as the child’s size changes.
A stander positions a child therapeutically for health benefits. Additionally, this equipment can enable a child to participate in an activity and perform a task. With appropriate support, a child can access materials, gain a good visual view and have their hands freed sufficiently to perform a task. By approximating a more normal postural position, equipment can facilitate appropriate and healthy posture, movement, and enable improved performance.
The standing posture can help develop and improve upper body strength and balance, and improve overall standing tolerance and endurance to prepare for the child’s transition to less restrictive and more mobile adaptive equipment for active standing and walking. Active weight-bearing and limb movement is essential for the development of strong and healthy bones. Many children with multiple disabilities have lower density bones and are at higher risk of fracture, because prolonged immobility and lack of activity results in a lack of healthy revitalization of bone tissue. The long-term goal of gains in postural control for more active weight bearing in standing and walking is essential for bone health.
The health benefits of being positioned in the upright standing posture include preventing contractures (hip, knees, ankles), reducing spasticity, and preventing pressure ulcers through the change of position. Standing can also alleviate pain or discomfort from other prolonged positions, can assist healthy skeletal development and lessen progressive scoliosis. Besides this, in the standing position, gravity positively effects almost all systems of the body. Regular standing opportunity can improve renal function and urinary tract drainage, improve bowel function, help respiration and breathing, and improve the body’s circulation.
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Straps and supports are provided for safe positioning and should be carefully adjusted for the comfort and security of the user. Adult supervision is required at all times.