Adaptive Standing for Contracture Management in Cerebral Palsy

Cerebral palsy (CP), one of the most common physical disabilities, is the result of a neural injury to the brain. There is a loss of neural connection resulting in altered muscle activation, weakness and fatigue. At the same time, there is a loss of inhibition resulting in muscle spasticity. Interestingly, this hypertonia and muscle weakness can occur in the same muscle. Although the actual injury is static and unchanging, the musculoskeletal effects of cerebral palsy often worsen as the child ages.

Determinants of contracture in cerebral palsy

The muscles in cerebral palsy have a markedly reduced volume and, although the tendons may be longer, the overall muscle is usually shorter in length. Other differences at the cellular level contribute to muscles not only being smaller and weaker, but also stiffer, with more tension and less extensibility than typical muscles (Handsfield 2022). These muscle deficits can result in a cycle of inactivity: as children with cerebral palsy engage in less physical activity, they have fewer opportunities to perform mechanical loading, which in turn results in greater muscle weakness and less muscle flexibility.

Structural abnormalities frequently increase with age and are evident beyond the growing years into adulthood (Ágústsson 2019). Children with cerebral palsy do not have any skeletal distortions at birth: their muscles and joints appear typical. However, during development, we observed the widely recognized combination of knee and hip flexion contractures, with progressive worsening of pelvic obliquity and hip rotation. These contribute to the lower extremity pattern known as windswept deformity, along with hip dislocation and scoliosis (Sato, 2022). These body distortions are more evident in children with postural asymmetry and decreased motor function (Nordmark 2009, Casey 2022, Casey 2022).

Knee contracture occurs in children at all GMFCS levels (Cloodt 2021, Cloodt 2002), with knee flexion contracture being the primary concern. There is an association between the severity of knee flexion contracture and reduced functional mobility, including decreased ability to stand and transfer (Pantzar-Castilla 2021). Recently, a scoliosis risk score has determined that limited knee extension is one of four predictors of scoliosis (Pettersson 2020). Knee contracture is notably associated with higher GMFCS levels, aging, and hamstring shortening. Muscle spasticity appears to have a minor effect on the development of contracture (Cloodt 2018).

Although this topic is beyond the scope of this article, it is interesting to consider that perhaps the squat gait pattern contributes to knee flexion contracture more than knee flexion contracture contributes to squat gait. . Factors such as muscle weakness, postural stability and balance influence crouch gait. In stance, weakness of the knee extensors contributes to knee flexion, while in the swing phase of gait, the range of motion of passive knee flexion modulates the knee pattern. As for muscle spasticity, it has a recognized role in knee flexion during walking: hypertonia of the knee extensors is the largest contributor to knee flexion in both the stance and swing phases. . (Manikowska 2022.)

While we recognize that muscle shortening occurs in cerebral palsy (Cloodt 2021, Cloodt 2022) and contributes to the deformity and a cycle of inactivity, the mechanisms of the structural changes that result in muscle contracture are not fully understood. Additional research is needed to determine the effectiveness of interventions that to date have included passive manual stretching, serial casting, bracing, and the use of standing devices. A Cochrane review published in 2010 with an abbreviated republication in 2017 concludes that stretching has no clinically important effects on joint mobility (Katalinic 2010, Harvey 2017). Previous publications indicated that the evidence is inconclusive to support or refute stretching to prevent contractures (Wiart 2008, Craig 2016, Eldridge 2016). Therefore, passive manual stretching in isolation is not considered an effective intervention for the treatment of contractures (Novak 2020).

Adaptive position for contracture management

However, published systematic reviews offer a positive perspective on the potential of supported standing to prevent or improve contractures (Paleg 2013, Occhipintti 2018, McLean 2023). And the following experimental studies included in these reviews describe positive results with children placed in adaptive supports.

In a 2009 study, five non-mobile children were placed in a standing position for one hour, five days a week, for six weeks (Gibson 2009). This was followed by six weeks without being on his feet. These phases were repeated. The hamstring muscles lengthened (reducing knee flexion contracture) during the standing phase and shortened during the standing phase.

A 2020 study compared static standing to dynamic movement in an upright position (Tornberg, 2020). Twenty non-ambulatory children between five and seven years of age were randomly assigned to a static or dynamic standing intervention for a minimum of thirty minutes daily for four months. After a two-week washout period, the children were placed on the other device for thirty minutes daily for four more months. Both interventions improved range of motion in hip abduction, external rotation, and extension. Interestingly, the opportunity for dynamic movement also increased the range of motion in opposite directions, i.e., flexion, adduction, and internal rotation. This may be less relevant to contracture, but is certainly interesting to observe.

A girl is standing on a Rifton Stander in a prone position with her hips abducted.

A retrospective longitudinal case-control study measured children’s hip abduction and knee extension (Martinsson 2021). It is interesting to note that the children began standing with support at a fairly early age, from just over one year to eleven years old, and the data was collected for seven years. The children stood for ten hours per week and the study groups remained between fifteen and thirty degrees of hip abduction. Children in the study groups did not develop any contractures. This 2021 contribution to research strongly indicates that adaptive abduction positioning can prevent contractures.

Additionally, a preliminary randomized controlled trial with ten children, published in 2022, was set up in the UK as a feasibility study in preparation for a future larger RCT (Rapson 2022). This twelve-month study enrolled children with cerebral palsy at GMFCS levels III, IV, and V. The researchers determined the children’s average initial standing time and then doubled their standing time for the intervention group. Participants used their existing standing frames and braces. The average daily standing time of the intervention group was fifty-eight minutes per day on weekdays and forty-nine minutes per day on average overall. The researchers measured the range of motion of the ankle, knee and hip. Children who spent more time standing showed a statistically significant improvement in knee and hip range, while children who continued to stand habitually showed a statistically significant improvement in knee and ankle range. Both groups showed an increase in knee ROM with the standing knee extension position.

The results of a single case study published in 2020 are also promising. A sixteen-year-old boy, GMFCS Level V, was placed in a support that accommodated his hip and knee flexion contractures. The average frequency of standing was three times per week for approximately one hour per session. For fifteen months, knee extension and hip extension were intentionally and gradually increased each week. At the same time, the overall angle of the stander gradually moved towards a more upright position.

Table 1 shows that the subject’s hip extension increased bilaterally and right knee extension also increased. Only left knee flexion remained essentially the same. Since this individual is sixteen years old, his contractures may be longstanding. Since this is a single case study, it does not carry much weight in terms of data. However, the results effectively support the concept of using adaptive standing to improve range of motion.

Table 1

hip flexion

Good

Left

Base

25°

40°

15 month post

20°

knee flexion

Good

Left

Base

40°

30°

15 month post

20°

35°

Table 1 shows the improvement in range of motion measurements.

Early and Permanent Intervention

It is exciting to consider the possible outcomes if we could start this intervention earlier. In Paleg and Livingstone’s 2022 evidence-based clinical perspectives on postural management, they encourage “supported standing in hip abduction of ten to fifteen degrees bilaterally (twenty to thirty degrees total) for at least one hour daily as a change.” important position from sitting or lying down.” starting at nine months of age. (Paleg 2022).

Similarly, the 2021 Morgan International Clinical Practice Guideline, based on systematic reviews, suggests the regular use of standing equipment for positioning as part of an active intervention program. This is especially recommended for children with or at high risk for cerebral palsy, at the age when standing weight-bearing would begin in non-weight-bearing children (Morgan 2021).

Cerebral palsy affects numerous people around the world, many of whom experience limitations in range of motion that negatively impact function. Recent research strengthens the available evidence supporting the use of adaptive posture for contracture management. If you can stand regularly at any age, you can maintain and potentially improve joint range of motion. And with adaptive standing in early intervention, particularly in the abduction position, the development of contractures can be completely prevented, allowing children with cerebral palsy to experience better musculoskeletal health, function, and quality of life.

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