"Are standing frames good or bad?"
As those who know me well would expect, my response would be far from a generic "yes / no". There is ALWAYS a contextual consideration to be made...at the very least.
WHAT standing frame will be used?
WHO is the standing frame intended for?
WHAT angle is the intended frame to be set?
HOW long do you plan on implementing it?
WHAT is the frequency per week / month?
WHAT is the status of the hips / legs?
..the list goes on.
In an effort to "open the brackets" and engage in the broader exploration, I think it is best to start with the most intuitive (and the most widely understood) rationale for their use. This rationale (in my experience) has been justified as follows:
"Vertical loads are good for the hips."
This statement is most certainly accurate in the developmental sense...however, in order for it to be given the blanket statement of being "TRUE", you need to add a modifier that makes it so. Therefore, the "truer" statement would be:
"Under healthy biomechanical situations, vertical loads are good for the hips."
This revised (and comparatively more complete) statement is unequivocally true...however, we all understand that disorders of movement and posture have varied and diverse unhealthy biomechanical manifestations. The discussions always generally come back to the original question..
"So they are bad then?"
Remember....CONTEXT.
I think the best way to approach the process of a broader understanding is to be a bit better (as professionals) in being explicit and defining our statements with much more precision. In other words, I would suggest that the statement actually be changed:
"Vertical AXIAL loads are good for the hips."
Let me unpack what may seem to be a nuance:
Under healthy biomechanical circumstances, you can be sure that the ground force reaction (the mechanical forces entering from the feet) will travel through the foot and ankle, traverse the knee, and ultimately end up in the hip. It is this repetitive "micro-stimulus" that is derived from crawling / walking that drives the evolution of the acetabulum (socket) and the overall development of the hip.
However, in a situation such as CP, the presence of multiple layers / levels of joint weakness, muscular imbalance, proprioceptive deficits, bony deformation, etc...makes it formally impossible to be completely sure that these ground force reactions are INDEED reaching the hip and not (perhaps) exiting the ankle or knee...or worse, de-stabilizing the joints more. The only way to ensure that the mechanical loads enter the hip is to (through specific and focused methods) generate a stimulus that you are sure travels along the axis of the bone.
"So now you're saying they are REALLY bad?"
C-O-N-T-E-X-T
(Finally) Here is how I would respond to the specific question of standing frames.
In truth, the question is not about whether standing frames themselves are "good or bad"...they are inanimate objects that cannot generate any benefit or damage until they are "attached" to a biological system. Therefore, the more appropriate question is:
"Are they good or bad for my child?"
To answer that question in the most comprehensive way, we have to get an even MORE broader perspective on CP rehab strategies in general. To be precise, EVERYTHING you do as a parent / professional / caregiver has to service one or all of the social, cognitive, physical needs of the person.
1. Does a standing frame service any social need? YES. The mere fact of being vertical...or at "eye level" with family, siblings, peers...presents and ENORMOUS benefit to anyone's social interaction and development
2. Does a standing frame service any cognitive need? YES. Being in the supported, semi-loaded position may facilitate better overall comfort and, as a result, allow for more mental resources to be freed up for cognitive tasks (school, arts, etc...)
3. Does a standing frame service any physical need? YES*. I purposely inserted the asterisk * here to highlight / remind us that it is the physical needs that the standing frame is most intuitively identified as being the "valuable" tool...but it requires some additional layers of analysis and thought.
It can be a reliable physical tool when:
a) The distortion in the feet / ankle / knees are minimal to moderate
b) There is no presence of extreme muscular tension
c) The pelvis is somewhat adequately prepared for some minimal amounts of load bearing
d) Proper consideration is given to the angle (greater the angle, the greater the mechanical loads)
e) The time spent in the frame does not exceed their tolerance level nor does it generate any muscular fatigue
f) Any empty spaces behind / between the knees and behind the hips and lower back can be filled. This potentiates a more neutral stance and thus, less excessive muscular activation / tension.
Therefore, are they good or bad? They are neither. The important element in the equation is the person to be placed in the standing frame. I would summarize in the following way:
"You need not be fearful of standing frames nor should you be too accepting of them. They can be "friend or foe"...therefore, as with anything as infinitely complex as the body, you need to implement a focused analysis on whether it is appropriate for YOU."
This is obviously a very "compact" narrative that can be expanded into the specific "axial loading techniques", the physiological response of bone, and the varied and diverse options for standing frame use...but I hope that this initial discussion does indeed "open some brackets" and stimulate some productive analysis and thought!
