Supported Standing For Head & Trunk Control

Chapter 1: Why Do Some Children Use Standers?

• Most infants are born with normally functioning musculoskeletal systems. The brain signals muscles to move, and healthy bones and joints function reliably, allowing them to sit, crawl and walk. 
• A baby born prematurely, with genetic differences, or brain injury may experience atypical neuromuscular signals, which eventually can impact how their bones, muscles and joints develop.
• When muscles move in unusual patterns (abnormal tone) or don’t move frequently enough, they tend to get tight (develop contractures).1 Since muscles attach to bones, and infants’ bones are soft and not fully formed, the pull - or lack of pull - from muscles can affect how the skeletal system is formed. 
• Growing up with complex medical conditions often puts children at 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:



• Hip-healthy positioning is essential for every infant to safeguard their developing hip sockets. Hip dypslasia is reported in nearly 15% of all newborns.4 In these instances, doctors 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. This is important for children who require support to stand. Using adaptive standers that can be positioned in hip abduction helps minimize the risk of hip dysplasia.⁵,⁶,⁷
• 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. 
• 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 Proper trunk supports in a stander can help children maintain this alignment while gradually building active strength in their necks and backs.
• 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
• Standing allows all muscles to get stronger. As children engage neck and trunk muscles during standing activities, their arms are able to reach better, they may speak or breathe more easily, or they may hold their head up longer to eat or learn. Standers help children become more successful and capable of using their arms, legs and back muscles without fear of falling. Every movement builds muscle strength and confidence to move more.

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:

• Assist the clinician during their child’s mat evaluation by helping their child remain relaxed and feel secure. Take photos of the child’s position lying down, and note where you place your hands for best alignment. This can help guide the placement of the trunk and hip laterals on the stander. Take photos from the side view and obtain joint angle measurements to ensure comfortable positioning of the child’s legs. 
• 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.
• Make adjustments starting from the base of support and moving upwards: Pelvis first, then the lower extremities and feet, followed by the chest, shoulders, and head. This step-by-step approach can improve overall alignment and improve proper activation of muscles.
• Refer back to the photos taken during the mat evaluation to confirm that the child has achieved their optimal position after setup.

Caregivers can gradually encourage more active trunk and head control through fun activities that require looking and reaching above shoulder level or to the sides. Examples include:

• Playing with a balloon or beach ball suspended on a string at eye level
• Reaching for bubbles in different planes
• Imaginative play with doll houses, car ramps, farm sets
• Use of an easel on the tray for coloring/painting

Beyond physical benefits, regular use of a stander often yields improvements in social skills, oral motor control, communication, vision, and hand-eye coordination and even digestive function such as bowel movements.¹¹

Consistency is KEY to developing head and trunk control!

• Start with daily short, engaging standing sessions paired with a snack or meals, or interactive play. Gradually build up the time or use multiple times per day, until your child stands for at least 45 minutes per day (mimimal recommended dosage¹⁰). 
• The stander can be tilted or remain more upright to increase or reduce challenge. Adjustments should not compromise alignment and stability, and may be done for short periods as tolerated. If the child shows signs of fatigue, they should be repositioned with more support. 
• As active control improves, lateral supports at the trunk can be lowered, and chest straps loosened or head rest removed to allow for greater upper body control and movement.

A stander gives children the extra time they need to actively improve head and trunk control safely.  This helps them develop better balance, increased endurance, and more confidence during everyday movement activities such as tummy time, sitting or standing.

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. 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