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Can a Passive Standing Program Improve Bone Density?

All material Copyright © May 2009 EasyStand
Reprinted with their express permission as originally published on their website.
By: Ginny Paleg, PT
Ginny is a pediatric Physical Therapist from Silver Spring, MD. She works in a 0-3 (Early Intervention) program for Montgomery County Public Schools. She recently completed her dissertation on Supported Standing and offers it as a free webinar on the EasyStand website.
The evidence linking passive standing and bone density is the strongest we found in our systematic review. While the data can be divided and analyzed in many ways, clinically the delineation between those that used traditional standing equipment and those that incorporated whole body vibration or oscillating standers seemed uniquely important. Whole body vibration (WBV) is a new application and while we found some promising literature, it is not widely accepted in mainstream Physical Therapy practice. The oscillating stander is also not commercially available or used in clinical practice.
We located ten studies that looked at passive standing and bone density in patient populations with diagnoses of neuromuscular dysfunction.
When looking at the results, we noticed a large variance in how the researchers measured bone density. Some looked at the vertebrae at different levels of the spine, some femoral head, others proximal and/or distal femur and even distal and proximal femur. When we looked at the literature as whole, there seemed to be a need to standardize which areas were measured. Pathological fracture is an issue in people with chronic disabilities. Poutney found that 80% of children with severe cerebral palsy (non-ambulatory) experience a pathological fracture. In the articles that discuss pathological fractures in children and adults with cerebral palsy and spinal cord injury, most cite the distal femur and proximal tibia as the most frequently fractured sites. Therefore, when reviewing the standing literature, the most weight was placed on those studies which showed improved bone density in these areas.
The evidence linking passive standing and bone density is the strongest we found in our systematic review.
Ward showed that standing in combination with whole body vibration resulted in improved proximal tibia bone density in non-ambulatory children with cerebral palsy after standing for 22 minutes per week (4.4 min/day x5 days/wk) . In this same population, Katz showed positive effects on bone density with 7.5 hrs/wk of standing, Gunjonsdittir in 2.5 hrs/wk (30 min/day 5 days/wk) in all the children who stood on oscillating standers and one of two who used a static stander, Stuberg with (60 min/day x7) 7 hrs/wk and Caulton 6.25 hrs/wk. This data, when looked at as a whole, suggests that children would need to stand for more than an hour a day at school (5 days/wk) to effect bone density. Caregivers may need to supplement school standing programs with an additional 30-60 minutes per day at home, especially during breaks and holidays.
In adults with spinal cord injuries, standing in long leg braces improved bone density better than standers or standing wheelchairs (Gomaere). After cessation of standing for just one week, the bones began to leach calcium (Kaplan). Kaplan also showed that standing was better than exercise for improving bone density in subjects with SCI while Birkhead found similar results in normal subjects (supine cycling vs standing).
All in all, the evidence for standing and bone density is good. More studies need to look at the combination of drugs (Pamidronates) that stimulate bone production along with standing programs. Wren, a group at AI DuPont and other are currently completing studies on whole body vibration and children with cerebral palsy and they report promising results, we eagerly await their publications.
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