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Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach 3 (2010) 197–213 197
DOI 10.3233/PRM-2010-0129
IOS Press
Review Article
A systematic review of supported standing
programs
Leslie B. Glickman∗, Paula R. Geigle and Ginny S. Paleg1
University of Maryland School of Medicine, Department of Physical Therapy and Rehabilitation Science,
Baltimore, MD, USA
Accepted 1 February 2010
Abstract.Objective: The routine clinical use of supported standing in hospitals, schools and homes currently exists. Questions
arise as to the nature of the evidence used to justify this practice. This systematic review investigated the available evidence
underlying supported standing use based on the Center for Evidence-Based Medicine (CEBM) Levels of Evidence framework.
Design: The database search included MEDLINE, CINAHL, GoogleScholar, HighWire Press, PEDro, Cochrane Library databas-
es, and APTAs Hooked on Evidence from January 1980 to October 2009 for studies that included supported standing devices
for individuals of all ages, with a neuromuscular diagnosis. We identified 112 unique studies from which 39 met the inclusion
criteria, 29 with adult and 10 with pediatric participants. In each group of studies were user and therapist survey responses in
addition to results of clinical interventions.
Results: The results are organized and reported by The International Classification of Function (ICF) framework in the following
categories: b4: Functions of the cardiovascular, haematological, immunological, and respiratory systems; b5: Functions of
the digestive, metabolic, and endocrine systems; b7: Neuromusculoskeletal and movement related functions; Combination of
d4: Mobility, d8: Major life areas and Other activity and participation. The peer review journal studies mainly explored using
supported standers for improving bone mineral density (BMD), cardiopulmonary function, muscle strength/function, and range
of motion (ROM). The data were moderately strong for the use of supported standing for BMD increase, showed some support for
decreasing hypertonicity (including spasticity) and improving ROM, and were inconclusive for other benefits of using supported
standers for children and adults with neuromuscular disorders. The addition of whole body vibration (WBV) to supported
standing activities appeared a promising trend but empirical data were inconclusive. The survey data from physical therapists
(PTs) and participant users attributed numerous improved outcomes to supported standing: ROM, bowel/bladder, psychological,
hypertonicity and pressure relief/bedsores. BMD was not a reported benefit according to the user group.
Conclusion: There exists a need for empirical mechanistic evidence to guide clinical supported standing programs across practice
settings and with various-aged participants, particularly when considering a life-span approach to practice.
Keywords: Supported standingprogram, supported standing equipment, supported standing device, tilt table
∗Corresponding author: Leslie B. Glickman, PT, PhD, Director
of Post-Professional Programs, Assistant Professor, 100 Penn Street,
205A, Baltimore, MD 21201, USA. Tel.: +1 410 706 4543; Fax: +1
410 706 6387; E-mail: lglickman@som.umaryland.edu.
1Based on research completed for DScPT capstone project.
1. Introduction
Supported standing programs, using various assis-
tive devices, are commonplace in pediatric practice set-
tings (including schools, daycare centers, and private
homes) [1–5] and for adults with spinal cord injuries
(SCI) [2,5]. While the use of supported standing pro-
grams appears routine, questions arise as to the nature
1874-5393/10/$27.50 2010 – IOS Press and the authors. All rights reserved
198 L.B. Glickman et al. / A systematic review of supported standing programs
Table 1
Database or search engine, search terms, and study findings (retrieved and selected)
Database or search engine Search terms # of studies # of studies
retrieved selected for review
Medline stand and cerebral palsy 46 35
stander and cerebral palsy 6 6
standing and spinal cord injury 196 42
upright positioning 25 22
stander and child 37 26
passive standing 26 26
spina bifida 0
meningomyelocoel 0
HighWire Press supine stander 1 1
prone stander 12 12
passive standing 56 37
prone board 3 3
Pedro Stander 0 0
standing and cerebral palsy 12 12
whole body vibration 10 10
Hooked on Evidence
(APTA) Stander 2 2
standing and cerebral palsy 12 12
standing and spinal cord injury 6 6
whole body vibration 24 10
spina bifida 0
meningomyelocoel 0
Google Scholar stander and cerebral palsy 262 45
Total studies (excluding
duplicates)487 112
Studies included 39 (10 pediatric; 29
adult participants)
Studies excluded 73
c
UMB 2009 All rights reserved.
of the evidence used to justify this practice. There is
clearly a need for a mechanistic understanding of the
supportedstandingevidence andrelationshipto clinical
practice.
A systematic review of supported standing programs
for a variety of age groups was conducted. Stud-
ies were evaluated and categorized using the Center
for Evidence-Based Medicine (CEBM) Levels of Evi-
dence (http://www.cebm.net/?o=1116). The outcomes
were classified using the International Classification
of Functioning, Disability, and Health (ICF) model
(http://www.who.int/classifications/icf/en).
2. Purpose of study
The purpose of this systematic review was to de-
termine the available evidence underlying supported
standing programs. While the initial purpose was to
explore in depth the literature on pediatric participants,
it soon became clear that there were a greater number
of studies with adult participants. This finding offers
potential application across all age spans as individu-
als with a primarily pediatric diagnoses transition into
adulthood as well as to inform pediatric practice.
3. Methods
3.1. Data identification, extraction, and sorting
Several databases and search engines (MEDLINE,
CINAHL, GooglesScholar, HighWire Press, PEDro,
Cochrane Library databases, and APTA Hooked on Ev-
idence) were searched using a uniform set of search
terms between January 1980 and October 2009. Ta-
ble 1 provides the database or search engine, the search
terms, and studies retrieved and selected for review.
Thesearchtermschosen were acceptedterminologyfor
standing, standing equipment, typical diagnostic cate-
gories of individuals who use standers, Guide to Phys-
ical Therapist Practice [6] terminology, and HCPCS
codes(HealthcareCommonProcedureCoding System:
http://www.nls.org/av/FAQ’s%20HCPCS.pdf).
L.B. Glickman et al. / A systematic review of supported standing programs 199
Fig. 1. Data sorting decisions; c
UMB 2009 All rights reserved.
Of the 487 identified study abstracts, we extracted
122 published in English in peer-reviewed journals us-
ing human participants of all ages, gender, neuromus-
cular diagnoses, and functional status for further anal-
ysis. The extracted group was reviewed in their full
text versions (if available) and included if a support-
ed standing device (equipment) was used and the data
from those participants was interpreted (analyzed) sep-
arately from other interventions (exercise, wheelchair
positioning, sleep systems, surgery, drugs, etc) and
available in full text (Fig. 1).
3.2. Data categorization
The studies of interest were further reviewed and
assigned a level of evidence independently by two in-
vestigators using the CEBM framework with discrep-
ancies decided by a third investigator, a clinical re-
searcher serving as the expert investigator (Table 2).
The CEBM framework levels range from 1–5, with
1 the highest level of evidence [systematic review of
randomized controlled trials (RCT)] and 5 the lowest
level [expert opinion without critical appraisal]. Level
5 studies were excluded because they have the great-
est degree of subjectivity. Utilizing categories 1-4, the
following suppositions were followed while evaluating
the reviewed studies:
1. Source authors’ exact terminology describing the
study design or type, the category of participant
ages (children or adults), or diagnosis was accept-
ed as true.
2. Studies with no comparison participant(s) and a
design that was a descriptive analysis of the par-
ticipant(s) before and after an intervention classi-
fied as “case report” (for a single participant) or
“case series” (for more than one participant). All
were categorized at Level 4.
3. Survey research categorized at Level 2c if there
was a pilot survey with reported validity and re-
liability. Survey studies using a novel survey
tool without reported validity and reliability yet
methodology with rigorous analysis, were cate-
gorized at Level 3b. Studies employing a novel
survey tool without reported validity and reliabil-
ity and holding limited methodology and analysis
description were categorized at Level 4.
3.3. Study types and participants (criteria)
From the 112 studies of interest, we included 39 and
excluded 73 for this review based on the CEBM criteria
and our assumptions for evaluating the evidence and
the following inclusion/exclusion criteria:
Inclusion criteria:
1. Published between January 1980 and October
2009 available in full text from English language
peer-reviewed journals.
2. Used supported standing equipment or device
(supine stander, prone stander, tilt table, upright
stander, long leg braces, stand-up wheelchair,
standing frame, standing box, oscillating stander,
whole body vibration platform in combination
with a standing frame)
3. Involved participants with neuromuscular diag-
noses.
4. Measured a systemic response to standing (phys-
iological, psychological, or functional) indepen-
dent of other positioning devices (wheelchairs,
sleep systems, etc.)
5. Reported survey answers from users and or PTs
on perceived outcomes from use of supported
standing equipment or devices
6. Included the same data set information from two
published studies, if both studies were reconsid-
ered by the authors using different criteria.
Exclusion criteria based on reading full text studies
(See Table 3):
1. Categorized at CEBM Level 5 (expert opinion).
2. Published as a professional presentation abstract
only.
3. Covered a systematic review or literature review
only.
4. Provided no comparative data before and after an
intervention and or outcome measures.
5. Included typical participants exclusively (not a
part of control group).
200 L.B. Glickman et al. / A systematic review of supported standing programs
Table 2
Oxford centre for evidence-based medicine levels of evidence (http://www.cebm.net/?o=1116)
Level Therapy/prevention,
aetiology/harm Prognosis Diagnosis Differential diagnosis/
symptom prevalence
study
Economic and decision
analyses
1a SR (with homogen-
eity∗) of RCTs SR (with homogeneity∗)
of inception cohort stud-
ies; CDR† validated in
different populations
SR (with homogeneity∗)
of Level 1 diagnostic
studies; CDR† with 1b
studies from different
clinical centres
SR (with homogeneity∗)
of prospective cohort
studies
SR (with homogeneity∗)
of Level 1 economic
studies
1b Individual RCT (with
narrow Confidence
Interval‡)
Individual inception co-
hort study with >80%
follow-up; CDR† valida-
ted in a single population
Validating∗∗ cohort
study with good††† ref-
erence standards; or
CDR† tested within one
clinical centre
Prospective cohort study
with good follow-
up∗∗∗∗
Analysis based on clinical-
ly sensible costs or alterna-
tives; systematic review(s)
of the evidence; and in-
cluding multi-way sensi-
tivity analyses
1c All or none§ All or none case-series Absolute SpPins and
SnNouts†† All or none case-series Absolute better-value or
worse-value analyses ††††
2a SR (with homogen-
eity∗) of cohort
studies
SR (with homogeneity∗)
of either retrospective
cohort studies or untrea-
ted control groups in
RCTs
SR (with homogeneity∗)
of Level >2 diagnostic
studies
SR (with homogeneity∗)
of 2b and better studies SR (with homogeneity∗)
of Level >2 economic
studies
2b Individual cohort
study (including low
quality RCT; e.g., <
80% follow-up)
Retrospective cohort
study or follow-up of un-
treated control individu-
als in an RCT; Derivation
of CDR† or validated on
split-sample§§§ only
Exploratory∗∗ cohort
study with good††† ref-
erence standards; CDR†
after derivation, or val-
idated only on split-
sample§§§ or databases
Retrospective cohort
study, or poor follow-up Analysis based on clinical-
ly sensible costs or alterna-
tives; limited review(s) of
the evidence, or single stu-
dies; and including multi-
way sensitivity analyses
2c “Outcomes” Resear-
ch; Ecological studies “Outcomes” Research Ecological studies Audit or outcomes
research
3a SR
(with homoge- neity∗)
of case-control studies
SR (with homogeneity∗)
of 3b and better studies SR (with homogeneity∗)
of 3b and better studies SR (with homogeneity∗)
of 3b and better studies
3b Individual
Case-Control Study Non-consecutive
study; or without consis-
tently applied reference
standards
Non-consecutive
cohort study, or very lim-
ited population
Analysis based on limited
alternatives or costs, poor
quality estimates of data,
but including sensitivity
analyses incorporating cli-
nically sensible variations.
4 Case-series (and poor
quality cohort and
case-control
studies§§)
Case-series (and poor
quality prognostic cohort
studies∗∗∗)
Case-control study, poor
or non-independent ref-
erence standard
Case-series or supersed-
ed reference standards Analysis with no sensitivi-
ty analysis
5 Expert opinion with-
out explicit critical ap-
praisal, or based on
physiology, bench re-
search or “first
principles”
Expert opinion without
explicit critical appraisal,
or based on physiology,
bench research or “first
principles”
Expert opinion without
explicit critical appraisal,
or based on physiology,
bench research or “first
principles”
Expert opinion without
explicit critical appraisal,
or based on physiology,
bench research or “first
principles”
Expert opinion without ex-
plicit critical appraisal, or
based on economic theory
or “first principles”
Produced by Bob Phillips, Chris Ball, Dave Sackett, Doug Badenoch, Sharon Straus, Brian Haynes, Martin Dawes since November 1998.
Updated by Jeremy Howick March 2009. http://www.cebm.net/index.aspx?o=1025.
The majority of the 39 outcome studies were clinical
trials with a small number of participants (generally,
under 50) that described or compared supported stand-
ingusewith another interventionortookmeasurements
before, during, and/or after the use of the standing de-
vice. Five of the studies were based on survey data,
with 58 to 386 participants. A few randomized con-
trolled trials existed with a designated control group,
acknowledged randomization of participants, with or
without single or double blinding.
L.B. Glickman et al. / A systematic review of supported standing programs 201
Table 3
Excluded studies by author with reasons for exclusion (73 studies)
Study Level 5 Before No use of Professional Systematic No comparative Typical
1981 supported presentation or lit data or outcome partici-
stander abstract only review measures pants
Abramson & Delogi 1960 ×
Ahlborg et al., 2006 ×
Aukland et al. 2004 ×
Bahjaoui-Bouhaddi et al. 1998 ×
Bakewell 2007 ×
Behrman, 2002 ×
Birkhead et al. 1964 ×
Bleck, 1980 ×
Bottos et al., 2001 ×
Brogen 1985 ×
Bubenko et al., 1984 ×
Chad et al., 1999 ×
Comarr, 1955 ×
Cybulski 1986 ×
Daniels et al. 2005 ×
Dauty et al., 2000 ×
Deshpande & Shields, 2004 ×
Finke & Muldoon, 2003 ×
Fontana et al., 2005 ×
Garrett et al., 2008 ×
Gear et al, 1999 ×
Gontkovsky & Huff, 2005 ×
Gould et al., 1955 ×
Green, 1993 ×
Gudjonsdittor & Stemmons-Mercer, 2002a ×
H¨
agglund etal., 2005 ×
Harvey, 2003 ×
Hawran & Biering-Sorensen, 1996 ×
Henderson, 2002 ×
Henderson, 1997 ×
Henderson, 1995 ×
Hendrie, 2005 ×
Huston 2001∗
Issekutz et al., 1966 ×
Ivey et al., 1981 ×
Ivey et al., 1980 ×
Jesinkey et al., 2003 ×
Jones et al., 2002 ×
Katz et al., 2006 ×
Kay, 1973 ×
Kim, 1961 ×
Kreutz, 2000 ×
Larson, 2000 ×
Lee & Lynn, 1990 ×
Machek & Cohen, 1955 ×
Macias, 2005 ×
Miedaner & Finuf, 1993 ×
Mogul-Rothman 2002 ×
Molinar, 1993 ×
Motloch, 1983 ×
Nash et al., 1990 ×
Naslund, 2007 ×
Otzel et al., 2008 ×
Paleg & Mauricio, 2000 ×
Phelps, 1959 ×
Pin, 2007 ×
202 L.B. Glickman et al. / A systematic review of supported standing programs
Table 3, continued
Study Level 5 Before No use of Professional Systematic No comparative Typical
1981 supported presentation or lit data or outcome partici-
stander abstract only review measures pants
Poutney et al., 2002 ×
Ragnarsson et al., 1981 ×
Ruys, 1988 ×
Sergeeva et al., 1978 ×
Stuberg, 1991 ×
Tanaka
Tepper, 1938 ×
Thompson et al., 2000 ×
Tihanyhi et al., 2007 ×
Torvinen et al., 2003 ×
van den Tillaar, 2006 ×
Vlychou et al., 2003 ×
Wilhite, 1954 ×
Wilton, 1977 ×
Wood & Tromans, 2001 ×
Yeh et al., 2001 ×
Zabel et al., 2005 ×
c
UMB 2009 All rights reserved;
∗Huston (some citations show Huston as the sole author of a study with the same title and publication date as Eng, 2001. Per discussion with
Eng (Oct 2009), only one article was published and the true reference is Eng et al. (2001).
3.4. Organization of key data
Primary outcome data were sorted using the ICF
classifications:
b4: Functions of the cardiovascular,haematological,
immunological, and respiratory systems
b5: Functions of the digestive, metabolic, and en-
docrine systems
b7: Neuromusculoskeletal and movement related
functions
Combination of d4: Mobility, d8: Major life areas
and Other activity and participation
These classifications support the American Phys-
ical Therapy Association’s (APTA) position (http://
www.apta.org/AM/Template.cfm?Section=Home&TE
MPLATE=/CM/ContentDisplay.cfm&CONTENTID=
50081). We also made the following decisions related
to our interpretation of the ICF classification system:
1. Cardiopulmonary functions measured included
b410 Heart, b415 Blood vessel, b420 Blood pres-
sure, b440 Respiration and b455 Exercise toler-
ance (ICF b4).
2. BMDislisted asb598,ametabolic function,since
there is no category for bone strength. The ICF
model makes it difficult to include consideration
such as calcium intake, nutritional status, thyroid
function, and all the other factors that could con-
tribute to BMD (ICF b5).
3. Bowel/Bladder included b525 Defecation and
d530 Toileting (ICF b5).
4. Pressure relief/bedsores included b810 Protective
functions of the skin, b820 Repair functions of
the skin, b830 Other functions of the skin and
s810 Structure of areas of skin (ICF b5).
5. Rangeofmotionwasincludedunderb710Mobil-
ity of joint functions; Muscle Strength and Func-
tion included b730 Muscle power, b760 Control
of voluntary movement, b770 Gait pattern, b789
Movement (ICF b7).
6. Hypertonicity included b735 Muscle tone, b750
Motor reflex and b765 Involuntary movement.
Balance was listed under b235 Vestibular func-
tions (ICF b7).
7. Psychological well-being included b130 Energy
and drive functions, and d820 School education
(ICF Combination).
8. Activities and participation included: d430 Lift-
ingandcarryingobjects,d440 Finehanduse d445
Hand and arm use, d449 Carrying, moving and
handling objects, d450 Walking, d455 Moving
around and d855 Non-remunerative employment
(ICF Combination).
9. Activities if daily living (ADLs) were classified
under d230 Carrying out daily routine (including
simulated self feeding) (ICF Combination).
4. Results
See individual Tables 4–7 with primary results by
specific ICF classifications for pediatric and adult par-
L.B. Glickman et al. / A systematic review of supported standing programs 203
Table 4
ICF- b4 (Functions of the cardiovascular, haematological, immunological, and respiratory systems) Adult participants only
Author Design Level Population Intervention Outcome measures Primary results
Luther et al.
(2008)9RCT with
single
blinding
2b N=9 un-
conscious
adults w/TBI
Used convention-
al tilt ×1 table &
tilt table with in-
tegrated stepping
device ×1
# of syncopes/presyn-
copes (orthostatic hy-
potension, tachypnea,
increased sweating)
during interventions
Significantly more presyncopes on
tilt table w/o than on the one with
integrated stepping device at tilts of
50 or 70 degrees respectively
Faghri &
Yount
(2002)7
RCT 2b N=28 (14
healthy
adults & 14
adults
w/SCI)
30 min stationary
standing &
30 min dynam-
ic standing with
FES for subjects
with SCI
Stroke volume, car-
diac output, HR, ar-
terial blood pressure,
total peripheral re-
sistance (TPR) dur-
ing supine-pre sitting,
sitting-pre standing, &
30 min of standing
For subjects with SCI, significant
reductions in systolic blood pres-
sure, diastolic blood pressure, &
mean arterial pressure in sitting to
standing & stationary standing &
maintained during dynamic stand-
ing. For healthy subjects values ma-
intained during standing sessions.
During 30 min of stationary stand-
ing, significant reductions in stroke
volume, cardiac output all sub-
jects, while peripheral resistance in-
creased. During 30 min of dynam-
ic standing, both groups maintained
haemodynamicsatpre-standing val-
ues except for reduction in stroke
volume at 30 min of standing
Faghri et al.
(2001)8RCT 2b N=14
adults w/SCI 30 min upright
with & w/FES in
stander compared
to standing w/o
FES
Stroke volume, car-
diac output, HR, arte-
rial blood pressure, to-
tal peripheral resistan-
ce (TPR), & rate pres-
sure product (RPP)
Cardiac output, stroke volume, &
BP significantly decreased during
passive standing, but maintained
during FES standing, RPP & HR in-
creased with FES standing
Eng et al.
(2001) 2Survey 2c N=126
adults w/SCI 17-item survey on
use of standers,
effects, & percei-
ved benefits
Subjective responses
to survey organized
into several categories
30% engaged in prolonged standing
(40 min/session); Perceived bene-
fits: circulation, akin integrity, re-
flex activity, bladder/bowel func-
tion, digestion, pain, sleep, fatigue;
cost a deterrent
Edwards &
Layne
(2007)10
Case
series 4N=4adults
w/SCI Exercise program
with dynamic
weight-bearing
device (DWB)
EMG, HR, & BP be-
fore & after
intervention
Subjects actively responded to exer-
cises during DWB w/positive phys-
iologic changes in EMG, HR, & BP
Jacobs et al.
(2003)11 Case
series 4N=15
adults w/SCI Protocol for sys-
tem of FES vs
frame-supported
passive standing
HR, open circuit
spirometry,
EKG, & metabolic ac-
tivity before & after
intervention
Significant improvement in pO2 for
FESvs passivestanding& lowerHR
in passive standing vs FES
c
UMB 2009 All rights reserved.
ticipants, then Table 8 for the results summary by
CEBM levels, and Table 9 for a summary of user out-
comes. Studies are not mutually exclusive to one cate-
gory because of the multiple purposes of several stud-
ies, particularly the surveys.
b4: Functions of the cardiovascular, haematologi-
cal, immunological, and respiratory systems (all adult
participants) (See Table 4)
Six studies were identified in this category from Lev-
el 2b to 4. At Level 2b, there were three RCTs. At
Level 2c, there was one survey. At Level 4, there were
twocaseseries. Participants included adults withspinal
cord injury and traumatic brain injury and compared
to healthy adults, with sample sizes ranging from 9 to
28 participants and 126 adult stander users for the sur-
vey. A tilt table with and without integrated stepping,
standing devices with and without functional electri-
cal stimulation (FES), and a dynamic weight-bearing
204 L.B. Glickman et al. / A systematic review of supported standing programs
Table 5a
ICF – b5 (Functions of the digestive, metabolic, andendocrine systems) Pediatric participants
Author Design Level Population Intervention Outcome measures Primary results
Caulton et al.
(2004)14 RCT (asses-
sor blinded) 1b N=52: 26
children w/
CP; 26 nor-
mal children
50% increase in regular stand-
ing duration or control (no in-
crease in regular standing du-
ration) groups over 9-month
period
Pre- & post-trial verte-
bral & proximal
tibial vTBMD mea-
sured with quantita-
tive computed tomog-
raphy (QCT) before &
after intervention
Intervention group showed a 6%
mean increase in vertebral vTB-
MD; no change observed in mean
proximal tibial vTBMD.
Ward et al.
(2004)12 RCT (dou-
ble blinded) 2b N=20 chil-
dren w/disa-
bling condi-
tions:
10 WBV; 10
control
Standing on active or placebo
devices, 10 min/day, 5 days/wk
X 6 months
Three dimensional qu-
antitative computed
tomography before &
after intervention
WBV group increased proximal
tibial BMD; control group de-
creased proximal tibial BMD;
vspine BMD change greater in
WBV group; diaphyseal bone &
muscle parameters did not show
a response to treatment
Taylor
(2009)13 Survey 2c N=386 sc-
hool-based
physical
therapists
20-item on factors in the pre-
scription and implementation
of standing frame programs
Subjective responses
to survey organized
into several categories
58.7% rated pressure relief as
most important benefit of stand-
ing; rated as very important or
important: increasing bone stren-
gth
Kecsemethy
et al.
(2008)4
Case series 4 N=20
w/CP Quantified weight bearing in a
passive stander for 30 min/ ses-
sion, 4–6 sessions, 8 wks, to-
tal of 108 sessions, comparing
2 standers
Tilt angle, foot plates
with load cells mea-
sure % of body weight
during standing
Variable weight loads during
standing from 37–101% of body
weight; factors identified: type
of stander and inclination; differ-
ence in body wt varied as much
as 29%
Herman et al.
(2007)3Case series 4 N=19
w/CP Quantified weight bearing in a
passive stander for 30 min/ ses-
sion, 3–6 sessions, 2 wks, total
of 110 sessions
Tilt angle, foot plates
with load cells mea-
sure % of body weight
during standing
Variable weight loads during
standing from 23–102% of body
weight, mean of 68%
Gudjons-
dottir &
Stemmons-
Mercer
(2002b)34
Case series 4 N=4
pre-school
children
w/severe CP
Phase one: stood 30min/day
5x/wk X 8wks, 2 subjects in
prone stander, 2 in oscillating
stander
Phase two: all subjects had 3
sessions on both standers
BMD of lumbar spine,
proximal & distal fe-
mur before & after
intervention
BMD increased in both subjects
in oscillating stander and one
subject in passive stander
c
UMB 2009 All rights reserved.
Table 5b
ICF – b5 (Functions of the digestive, metabolic, and endocrine systems) Adult participants
Author Design Level Population Intervention Outcome measures Primary results
Ben et al.
(2005)30 RCT (asses-
sor blinded) 1b N=20
adults w/SCI 36 bouts (30 min/bout) over 12
wks on tilt table with 1 foot on
a 15-degree wedge; other foot
hung free (control)
ROM measured with
torque wheel, BMD
measured
w/DEXA scan before
and after intervention
Very slight increase in BMD
Goemare et
al. (1994)19 Cohort
study 2b N=53
adults w/SCI Divided into 3 groups: 38 w/
daily standing for at least 1 hr, 3
times/wk, & 15 w/no standing
X-ray absorptiometry
at L3 & L4, proxi-
mal femur & femoral
shaft, & by single-
photon absorptiome-
try at forearm before
& after intervention
Standinggroup had better-preser-
ved BMD at femoral shaft but
not at proximal femur, than pa-
tients not standing; BMD at lum-
bar spine(L3, L4) was marginally
higher in standing group; Stand-
ing with use of long-leg braces
had significantly higher BMD at
proximal femur than using stand-
ing frame or standing wheelchair
L.B. Glickman et al. / A systematic review of supported standing programs 205
Table 5b, continued
Author Design Level Population Intervention Outcome measures Primary results
Eng et al.
(2001)2Survey 2c N=126
adults w/SCI 17-item survey on use of
standers, effects, & perceived
benefits
Subjective responses
to survey organized
into several categories
30% engaged in prolonged stand-
ing (40 min/session); Perceived
benefits: circulation, akin integ-
rity, reflex activity, bladder/ bow-
el function, digestion, pain, sleep,
fatigue; cost a deterrent
Hoenig et al.
(2001)17 Case report 3b N=1 adult
w/SCI Stood 5x/wk X1hr/day Symptoms of consti-
pation; freq of bowel
movements, duration
of bowel care in min
before & after interve-
ntion
Standing imp constipation & de-
creased bowel care time
Dunn et al.
(1998)5Survey 3b N=99
adults w/ SCI 84% used their standers
41% used stander 1-6x/wk Novel tool
Focus group may have
established validity,
not clear
No reliability testing
21% reported decreased in UTI
and inc bladder emptying w/
stander use. Amt of standing cor-
related with reported more regu-
lar bowel movements
Netz et al.
(2007)18 Case series 4 N=13
adults (resi-
dents of nurs-
ing home,
mean of
82 years)
Supported standing device use
from 13–60 sessions with mean
standing time of 16 minutes
MMT, ROM, reach-
ing tests, independent
standing, distance wa-
lked w/ walker, FIM
Statistically significant improve-
ment in sphincter control
Shields &
Dudley-
Javoroski
(2005)
Case Report 4 N=1 adult
w/ SCI Average 12 min 4x/wk at 61deg
upright in standing w/c Questionnaire every 3
months for 12 months Reported improvements in bowel
Frey-Rindo-
va et al.
(2000)20
Case series 4 N=29
adults w/SCI
(27 male) w/
paraplegia &
tetraplegia
Comparisons at 6, 12, &
24 months post injury BMD of radius, ulna,
& tibia Significant decrease in BMD
over time, greater insubjects with
tetraplegia; significantly lesser
loss (1.5% & 3%) in 2 subjects
who performed regular standing
1 hr/4X per wk
deBruin et al.
(1996)35 Case series 4 N=19
adults
w/acute SCI
13 subjects divided into 2
groups: 6w/supportedstanding
&treadmill walking w/BWS,
7w/regular rehab program, &
controlgroupw/no intervention
BMD measured with
peripheral computed
tomography
& flexural wave prop-
agation velocity with
biomechanical testing
method before & after
intervention
Early loading in stander main-
tained or slowed decreased of tra-
becular bone
Kaplan et al.
(1981)16 Case series 4 N=10
adults w/SCI 20min 1x/day >45 deg angle
on tilt table & strengthening Calciuria measured
with urine analysis be-
fore & after interven-
tion
Standing better at decreasing cal-
ciuria than exercises, early group
(within 6 months of injury) ben-
efited more than late group (be-
tween 12 & 18 months post
injury)
Walter et al.
(1999)15 Survey 4 N=99
adults w/ SCI Respondents stood >
30min/day Same data as Dunn
Novel tool
Focus group may have
established validity,
not clear
No reliability testing
Dailyusedled tostat sigimprove-
ment in fewer bladder infections
and improved bowel regularity
c
UMB 2009 All rights reserved.
206 L.B. Glickman et al. / A systematic review of supported standing programs
Table 6a
ICF – b7 (Neuromusculoskeletal and movement related functions) Pediatric participants
Author Design Level Population Intervention Outcome measures Primary results
Tremblay et
al. (1990)21 RCT 2b N=22 w/
CP;12 exper-
imental w/
intervention,
10 control
Standing with feet dorsiflexed
on a tilt-table for 30 min vs.
control group kept at rest
TorqueE MGbefore &
after intervention Standing in dorsiflexion group
had stats sig decrease in spastici-
ty; inhibitory effects lasted up to
35 min
Semler et al.,
(2008)22 Case series 4 N=8 chil-
dren w/OI,
types III &
IV
WBV applied using vibrating
platform on tilting table X 6
months 2x/day 9 min total per
session WBV & 6 min total
standing w/o WBV
Brief Assessment
of Motor Function
(BAMF), tilt angle be-
fore & after interven-
tion
Improved BAMF; increased
tilting-angle (median =35 de-
grees) & increased in ground re-
action force
Semler et al.
(2007)23 Case series 4 N=6 chil-
dren (4w/OI
type III &
IV, 1 w/CP,
&1 w/lumbar
spine defect)
WBV applied using vibrating
platform on a tilting table x 6
months 2x/day 9 min total per
session WBV and 6 min total
standing w/o WBV
Brief Assessment
of Motor Function
(BAMF), tilt angle be-
fore & after interven-
tion
Improved BAMF score; increa-
sed tilt angle
c
UMB 2009 All rights reserved.
Table 6b
ICF – b7 (Neuromusculoskeletal and movement related functions) Adult participants
Author Design Level Population Intervention Outcome measures Primary results
Baker
(2007)36 RCT 2b N=6
adults w/MS
(wheelchair
dependent)
3x/wk X 3 for 30 min ex pro-
gram in standing frame vs 3
3x/wk X 3 for 30 min ex pro-
gram lying down
Ashworth, self-report
spasm scale before &
after intervention
Increase in range of motion of the
ankleandhip withuseof standing
frame; downward trend in spas-
ticity for knee flexion and ankle
dorsiflexion in standing group &
downward trend in reduction of
spasm for both groups
Allison &
Dennet
(2007)37
RCT 2b N=17
adults
w/CVA
Conventional physical therapy
(PT) 45min vs. PT plus stand-
ing 45min 14-28 days
Rivermead Motor As-
sessment (Gross Fun-
ctional Tool), Trunk
Control Test & Berg
Balance Scale before
& after intervention
Stat sig .Berg improved, trend in
Rivermead GM in PT & standing
group over PT alone
Bagley et al.
(2005)38 RCT 2b N=140
adults
w/acute CVA
(severe)
Usual PT vs PT plus standing
20–30 min/day X 14 days Rivermead Mobility
Index (RMI), Barthel
Index, Rivermead
Motor Assessment
(RMA), Motor Asse-
ssment Scale (sitting
& balance), Motor
Trunk Control Test
before & after inter-
vention
No difference in outcome mea-
sures nor resource savings from
use of Oswestry Standing Frame
Eng et al.
(2001)2Survey 2c N=126
adults w/SCI 17-item survey on use of stan-
ders, effects, & perceived
benefits
Subjective responses
to survey organized
into several categories
30% engaged in prolonged stand-
ing (mean of 40 min/session) 3-
4X/wk; perceived benefits: im-
proved ability to straighten legs,
decreased reflex activity, im-
proved skin integrity
Chang
(2004)25 Survey 3b N=58
PTs Survey on use of standers in
ICU Response to survey
items (unknown # of
items)
Perceived benefits: 81% iden-
tified improved strength, 70%
identified increased arousal
L.B. Glickman et al. / A systematic review of supported standing programs 207
Table 6b, continued
Author Design Level Population Intervention Outcome measures Primary results
Richardson
(1991)31 Case report 3b N=1 adult
w/TBI Tilt table regime to passively
stretch Achilles tendon over 27
days after conventional PT
Pain during stretching
period, ROM of ankle
joint
Improved ROM and tolerance for
standing
Walter et al.
(1999)15 Survey 4 N=99
adults w/ SCI Respondents who stood >
30min/day Same data as Dunn
Novel tool
Focus group may have
established validity,
not clear
No reliability testing
Daily used led to stat sig im-
provement in ROM, spasticity
and bedsores
Dunn et al.
(1998) 5Survey 4 N=99
adults w/ SCI 84% used their standers
41% used stander 1-6x/wk Novel tool
Focus group may have
established validity,
not clear
No reliability testing
42% reported decreased in spas-
ticity w/ standing
Amount of time spent standing
correlatedw/reporteddecrease in
spasticity
38% reported standing improved
their leg ROM
Netz et al.
(2007)18 Case series 4 N=12
adults nurs-
ing home
residents
Activity program performed in
standing box MMT
ROM
Reaching tests
Standing time
Distance walked w/
walker
FIM
Statsignificantincreasein streng-
th in hip and knee extensors, ab-
duction, and all ankle motions;
None of the subjects could stand
or walk at beginning of study, at
conclusion60%couldstand inde-
pendently and walked w/walker
Singer et al.
(2003)24 Case series 4 N=40
adults
with TBI and
contractures
Prolonged weight bearing
stretches (upright on tilt table) PROM
Ashworth Scale
Barry-Albright Dysto-
nia Scale
23/40 improved PROM with
standing alone
Dystonia was best predictor of
failure of standing alone to im-
prove PROM
Tsai et al.
(2001)26 Case series 4 N=17
adults
w/ CVA
30 min plantarflexor stretch on
tilt table MAS
ROM
Evoked potentials
ROM increased, plantar flexor
spasticity decreased and tibialis
anterior spasticity increased
Kunkel et al.
(1993)39 Case series 4 N=6
adults:
4 w/SCI,
2 w/MS
Standing time averaged 144 hrs
over 135 mean days H-reflex, deep tendon
reflexes (DTR), clo-
nus before & after
intervention
No change in H-reflex, DTR, &
clonus
Bohannon &
Larkin
(1985)29
Case series 4 N=20
adults
w/CVA &
other
Stood 30 min, 5–22 sessions,
2–6X/wk Goniometry before &
periodically before
stretch
Increased passive ankle dorsi-
flexion (mean of 8 degrees for en-
tire period)
Odeen &
Nutsson
(1981)40
Case series 4 N=9 adults
w/SCI Stood 30 min for 4 days (8 ses-
sions): 3 conditions: stretch in
supine, standing with dorsiflex-
ors stretched & loaded & stan-
ding with plantarflexors stret-
ched & loaded
EMG to measure re-
sistance to passive
movements at 3 differ-
ent speeds
Spasticity decreased with all
conditions, but decreased most
standing with plantarflexors
stretched & loaded
Shields &
Dudley-
Javoroski
(2005)
Case
Report 4N=1 T10
adult w/ SCI Average 12 min 4X/wk at 61◦
upright in standing wheelchair Questionnaire every 3
months for period of
12 months
Reported improvements in
spasticity
Bohannon
(1993)28 Case report 4 N=1
adult
w/SCI
Tilt table standing, 5 non-
consecutive days at 80◦X
30 min
Modified Ashworth
(MAS) & pendulum
testing before & after
intervention
Decreased spasm & spasticity
c
UMB 2009 All rights reserved.
208 L.B. Glickman et al. / A systematic review of supported standing programs
Table 7a
ICF – Combination d4 (Mobility), d8 (Major life areas), and Other activity and participation (Pediatric participants)
Author Design Level Population Intervention Outcome measures Primary results
Noronha et
al. (1989)32 Case series 4 N=10 chil-
dren w/CP:
(2 groups)
Twosets of tests of hand
function while sitting & prone
standing
Rate of manipulation
measured w/Jebsen-
Taylor Hand Function
Test & Hohlstein test
for quality of grasp on
each subtest of
Jebsen-Taylor test in
both positions
No significant diff on Jebsen-
Taylor test; for simulated feed-
ing & picking up small objects
performed significantly faster in
prone standing
c
UMB 2009 All rights reserved.
Table 7b
ICF – Combination d4 (Mobility), d8 (Major life areas), and Other activity and participation (Adult participants)
Author Design Level Population Intervention Outcome measures Primary results
Eng et al.
(2001)2Survey 2c N=126
adults w/SCI 17-item survey on use of
standers, effects, & perceived
benefits
Subjective responses
to survey organized
into several categories
30% engaged in prolonged stand-
ing (40 min/session); Perceived
benefits: circulation, skin integri-
ty, reflex activity, bladder/bowel
function, digestion, pain, sleep,
fatigue; cost a deterrent
Chang
(2004)25 Survey 3b N=58 PTs Survey on use of standers in
ICU Response to survey
items (unknown # of
items)
70% identified increased arousal
Dunn et al.
(1998)5Survey 3b N=99
adults w/SCI 42-item survey on use of
standers, effects, & perceived
benefits
Subjective responses
to survey organized
into several categories
Decreased spasticity w/ standing
correlated with amount of time in
standing
Walter et al.
(1999)15 Survey 3b N=99
adults w/SCI 42-item survey on use of
standers, effects, & perceived
benefits
Same data as Dunn
Novel tool
Focus group may have
established validity,
not clear
No reliability testing
Daily stander use led to statisti-
cally significant improvement in
ROM, spasticity, & bedsores
Nelson &
Schau
(1997)33
Case report 4 N=1 adult
w/ CP Client work seated vs in stander
vs unsupported standing Work output measure
in 3 positions Subject performed more “work”
while in stander than other two
conditions
Riek et al.
(2008)41 Case series 4 N=5 adults
w/ SCI Standing frame compared to
sitting rest posture, weight re-
lief raises, transfers, & stand-
ing depression lifts for shoulder
position
Flock of birds magnet-
ic tracking to measure
3-dimensional positi-
ons of the scapula, hu-
merus, & thorax dur-
ing various activities
Standing in frame results in less
scapular anterior tilt & greater
glenohumeral external rotation
than standing depression lifts &
weight relief raises
c
UMB 2009 All rights reserved.
L.B. Glickman et al. / A systematic review of supported standing programs 209
Table 8
Summary of intervention studies sorted by CEBM levels and outcomes
ICF outcome Subjects CEBM Levelandsource
w/ positive outcomes CEBM Levelandsource
w/ negative outcomes CEBM Level and cita-
tion w/ no difference
Cardiopulmonary
ICF b4 Adults (>21) II 9
II 7,8
IV Edwards 10
II 7−9
BMD
ICF b5
Functions of the digestive, metabol-
ic and endocrine systems
Adults (>21) II19
II19
III35
IV16
I30
II 16
IV 40
Children (0-21) I114
II12
IV34
I30
II 13,14
Bowel
ICF b5 Adults (>21) II2,18
III5,15,17
IV27
Hypertonicity
ICF b7 Adults (>21) II39
II 2
III5,15,31
IV26,33,41
II 39 II35
IV40
Range of Motion
b710 Mobility of joint functions Adults (>21) I30
II2,36
III 5,15
IV18,28
I30 IV40
Muscle Strength & Function
ICF d4 Adults (>21) IV33
IV 41
IV18
I39
II36,37
Children (0-21) II21
IV22,23,32 II 20
Table 9
Summary of user/therapist outcomes sorted by CEBM levels and results
Outcome User/Therapist CEBMLevelandsource
w/ positive outcomes CEBMLeveland source
w/ negative outcomes CEBM Level and cita-
tion w/ no difference
Cardiopulmonary
ICF b4 Adults w/ SCI who
used a stander regularly II2
BMD
ICF b5
Functions of the digestive, metabol-
ic and endocrine systems
School-based PTs II13
Bowel and Bladder
ICF b5, d5 Adults w/ SCI who
used a stander regularly II25
III2,5,15,17
IV 18,27
III5
Pressure relief/bedsores
ICF b5 School-based PTs
Adults w/ SCI II2,13
III5,15,25
Muscle Strength and Function
ICF b7 Acute Care PTs in an
ICU III 25
Range of Motion
ICF b7 Acute Care PTs in an
ICU
School-based PTs
Adults w/ SCI
II13
II 2,26
III 5,15,25
IV r24
III5
Hypertonicity
ICF b7 Adults w/ SCI who used
a stander regularly II2,26
II 2,15,25
IV 27
III5
210 L.B. Glickman et al. / A systematic review of supported standing programs
standing device comprised the interventions. Outcome
measures (pre/post) included EKG studies, heart rate
(HR), blood pressure (BP) and measures of hemody-
namics (snycopes, tachypnea, orthostatic hypotension,
and cardiac measures) for the interventions. For the
stander users, measures were their perceived benefits
of use.
A surprising finding indicated passive supported
standing alone had negative systemic effects on the car-
diovascular system [7–11]. Both the individuals with-
out SCI and those with SCI showed a decrease in car-
diac output and stroke volume with 30 minutes of pas-
sive standing, but stroke volume decreased less for in-
dividuals without SCI [7]. Of the three Level 2b stud-
ies, two found combining FES with standing signifi-
cantly improved the cardiovascular systems’ responses
to standing in participants with SCI through the preven-
tion of orthostatic hypotension [7,11]. Both the Level 4
studies concurred that “active” standing (using FES or
voluntary movements) resulted in more stable hemody-
namics than with the use of passive standing alone [10,
11]. The user survey noted 30% engaged in an average
of 40 minutes/session of regular standing with the fol-
lowing perceived benefits: well being, circulation, skin
integrity, reflex activity, bowel ad bladder function, di-
gestion, sleep, pain and fatigue. Equipment cost was a
deterrent [2].
b5: Functions of the digestive, metabolic, and en-
docrine systems
Seventeen studies from Level 1b to 4 were identified
in this category, six with pediatric and 11 with adult
participants (See Tables 5a and b).
Pediatric participants: At Level 1b and 2b, there was
one study each. At Level 2c, there was one study (a sur-
vey). At Level 4, there were three studies. In this cate-
gory, the number of participants ranged from four to 53
and included, typical children, children with “disabling
conditions [12]”, and children with CP for the clinical
studies and 386 school-based PTs for the survey. Three
of the six studies focused on BMD and two investigat-
ed the amount of body weight borne through the lower
extremities during standing. Two of the studies had a
control group of typical children. Interventions includ-
ed use of a tilt table or standing devices (static, vibrat-
ing, and oscillating) over a period of time up to nine
months with a frequency of daily to five times/week.
Intervention study outcomes measured BMD, percent
of body weight exerted against load cells, tilt angle, and
type of standing device. The survey of school based
PTs measured their perceived benefits and outcomes of
standing frame programs.
Ofsignificancefrom the surveywas respondentrank-
ingofthe followingtopthree reasonsforusing standers:
to provide pressure relief from sitting, promote social
interaction, and improve bone strength [13]. For the
RCT studies, there was significant increase in verte-
bral BMD but not tibial BMD [12,14]. The addition
of whole body vibration (WBV) to supported stand-
ing activities improved BMD at the proximal tibia in
children with CP, one of the two sites most at fracture
risk for these children [12]. Two studies noted variable
weight loads from 23 to 102% of body weight depen-
dent on body alignment in the stander [3,4] and type of
device [3].
Adultparticipants: AtLevel 1band2b, therewasone
study each. At Level 3b there were two studies, a case
report and a higher level survey. At Level 4, there was
another case report, one survey, and four case series. In
this category, the number of participants ranged from
one to 99 adults with the diagnosis of SCI primarily.
For the surveys, the participants were regular stander
users.
Findings from the surveys reflected user perceived
outcomes, including a positive effect on digestion
(bowel and bladder) as well as decreased time needed
for bowel care [2,5,16]. These findings were similar to
results from two interventionstudies [17,18]. The most
significant finding from the non-survey studies: partic-
ipants using long-leg braces in the standing device had
significantly higher BMD at the proximal femur than
those who did not stand using braces [19]. Standing
on a tilt table decreased calciuria more than exercise
for the group of individuals with SCI during the 1st
six months post injury [16]. There was a statistically
significant improvement in strength, standing, walking,
and sphincter control after use of a standing support
device in adult residents of a nursing home [18]. One
study found less reduction in BMD in two participants
with SCI who used a regular standing routine versus
those who did not have one [20].
b7: Neuromusculoskeletal and movement related
functions
Twenty studies were identified in this category from
Level 2b to 4, three with pediatric and 16 with adult
participants (See Tables 6a and b).
Pediatric participants: At Level 2b, there was one
study. At Level 4, there were two studies. Participants
included children with CP and OI ranging from six to
22 in number. Outcome measures included EMG, tilt
angle, percent of body weight on supporting limbs dur-
ing standing, and the Brief Assessment of Motor Func-
tion (BAMF). Interventions included supported stand-
L.B. Glickman et al. / A systematic review of supported standing programs 211
ing with and without ankles in a dorsiflexed position,
with and without WBV, and ability to tolerate increased
tilt table angle. Important findings included a statis-
tically significant decrease in spasticity of plantarflex-
ors [21] and improved BAMF scores [22,23].
Adult participants: At Level 2b, there were three
studies. At Level 2c, there was one study, a survey. At
Level 3b, there weretwo studies. At Level4, there were
ten studies. Participants included one to 140 adults
with primarily the diagnoses of SCI, CVA, TBI, and
MS and 58 PTs for the survey.
For the clinical studies, interventions included rou-
tine PT programs and specific standing programs with
or without a focus on specific activities, and varied at-
tention to specific ankle positions. Outcome measures
included Ashworth, modified Ashworth, self report-
ed spasm scale, Barry-Albright Dystonia scale (BAD),
deep tendon reflexes (DTR), EMG, pendulum test,
evoked potentials, ROM, manual muscle tests, specif-
ic functional measures [Functional Independence Mea-
sure (FIM)], Rivermead, Berg balance test, physiologic
measures, pain tolerance to the upright position, and
other tests.
The most common findings from the clinical studies
were increased ROM and decreased hypertonicity. One
studyoftheresidents of anursinghomewho performed
exercises in a standing box showed increased hip and
lower extremity strength and improved ability to stand
independently and walk using a walker [18]. The user
surveys,reportedimprovedROM, decreasedspasm and
spasticity, and improvement in strength [2,5,15,24]. In
thesurveyof PTsinthe ICU,94.8%felt thepurpose was
to“facilitateweight bearing[25].” Fromthe caseseries,
findings included decreased spasm and spasticity [26–
28] and improved ROM [20,24,29,31].
Other: Combination of d4: Mobility, d8: Major life
areas and Other activity and participation
Seven studies were identified in these categories
from Level 2c to 4, one with pediatric andsix with adult
participants (See Tables 7a and b).
Pediatric participants: At Level 4, there was one
study. Participants were children with CP (10 partici-
pants). Outcome measures were tests measuring qual-
ity of hand function and grasp. The most significant
finding was greater speed in picking up small objects
and simulated feeding [32].
Adult participants: At Level 2c, there was one study.
At Level 3b, there were three studies (surveys). At
Level 4, there were two studies. Participants for the
clinical studies were from 1 to 126 adults with SCI and
TBI. For the surveys, participants were 99 stander users
and 58 PTs working in an intensive care unit (ICU).
Intervention measures were user and PT surveys on use
of standers and perceived benefits as well as shoulder
position and work activities in a standing frame.
User survey findings included benefits from per-
ceived value from the use of supported standers re-
lated to ROM, psychological factors, bowel and blad-
der function, pressure relief/bed sores, and hypertonic-
ity [2,5]. The most significant findings for the case re-
port was improved work output [33]. The most signif-
icant finding from the PTs was increased arousal with
standing, in addition to changes previously noted in
ICF b7 [25].
5. Discussion: Clinical practice and research
implications
After systematically reviewing the supported stand-
ing pediatric and adult literature based on ICF classi-
fications and CEBM categories, conclusions were dif-
ficult to draw as the literature varied greatly in study
design, intervention, and outcome measures. Table 8
summarizes the results by CEBM levels for pediatric
and adult participants. For all participants, the avail-
ableinformationmoderatelysupportsthe beneficialim-
pact upon BMD and indicates potentially positive out-
comes for improving range of motion, spasticity, and
bowel function. Because of the variable weight loads
borne through the feet in supported standing, therapists
mustconsiderbody alignment, angleofinclination,and
type of stander in relationship to goals of the standing
program. There was a potentially negative cardiopul-
monary side effect from standing in participants with
SCI. With the exception of ROM, the supported stand-
ing perceived outcomes and benefits reported by ther-
apists and stander users were not consistent with the
non-survey literature-measured outcomes. Therapists
and stander users felt supported standing had positive
effects on weight bearing, pressure relief, ROM, and
psychological well being.
The apparent limitations of the supported standing
body of knowledge include lack of study design rig-
or, limited standardization of supported standing proto-
cols, and large variance in outcome measures. Clinical
practice is difficult to replicate via research, but practi-
tioners should seek a closer alignment and understand-
ing of the relationship between mechanistic outcomes
and clinical goals. Future supported standing clinical
investigations need to define intervention outcomes in
a more rigorous manner, particularly for pediatric par-
ticipants, considering the following:
212 L.B. Glickman et al. / A systematic review of supported standing programs
1. Quantified weight bearing on the axial skeleton
and lower extremities and postural alignment,
with the use offorce transducers, scales, and load-
ingdevicesto showactuallowerextremityweight
bearing.
2. Dosage of standing programs including duration,
position, frequency,equipment utilized, andtasks
performed during standing.
3. Outcome measures addressing specific ICF areas
including behavioral and cognitive abilities com-
bined with the physiological and functional skill
areas utilized currently.
4. Outcome measuresforeach participant group, for
example BMD in children with CP at sites where
fractures usually occur:
5. FES and or WBV combined with supported
standing, to enhance outcomes.
Using evidence-based practice, it is currently challeng-
ing to construct a standing protocol prescription for a
given participant, and equally complicated to select op-
timal targeted outcomes. Considerations for practicing
therapists are to combine the results of this systematic
review with sound clinical judgment based on support-
ed stander usage rationale in their particular setting.
Limitationsofthissystematic reviewincludedpoten-
tial reviewer subjectivity in the interpretation of results,
offset by the use of three reviewers, variable sets of
studies identified on repeated search attempts offset by
multiple searches performed on several dates, and re-
viewer choices for classification schema to sort the data
and interpret the results, offsetby taking into considera-
tion professional organizational recommendations and
generally-accepted practice.
Conflicts of Interest
None reported.
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