Medicine, Faculty of
Non UBC
Occupational Science and Occupational Therapy, Department of
DSpace
International Journal of Environmental Research and Public Health 21 (6): 669 (2024)
Paleg, Ginny S.
Williams, Sian A.
Livingstone, Roslyn W.
Children functioning at Gross Motor Function Classification System (GMFCS) levels IV–V cannot maintain an aligned standing position or take steps without support. Upright positioning and mobility devices have psycho-social significance for these children and their families, enhancing use of vision, communication, functioning and emotional well-being. Standers and supported stepping devices facilitate opportunities for biomechanical loading, potentially helping to build and maintain muscle and bone integrity, and they promote physical development. However, families are often required to choose between these two devices for their young child. This study aims to synthesize evidence for use and benefits of both supported standing and stepping devices through the lens of two contemporary theoretical frameworks to support clinical reasoning and implementation. The F-words for childhood development (functioning, family, fitness, fun, friends, future) and the interdependence-Human Activity Assistive Technology (iHAAT) models were combined to illustrate the complex interactions between the child, family, caregivers, peers and contextual factors when implementing standing and stepping devices with children at GMFCS levels IV and V. Supported standing and stepping devices provide complementary benefits, and both may be necessary starting at 9–15 months. We propose they both be included ON-Time, along with other age-appropriate positioning and mobility devices, to promote more equitable developmental opportunities for children with non-ambulant cerebral palsy.
Citation: Paleg, G.S.; Williams, S.A.;Livingstone, R.W. Supported Standingand Supported Stepping Devices forChildren with Non-AmbulantCerebral Palsy: An Interdependenceand F-Words Focus. Int. J. Environ.Res. Public Health 2024, 21, 669.https://doi.org/10.3390/ijerph21060669Academic Editors: Paul B. Tchounwou,Lidia Perenc, Agnieszka Guzik andMariusz Druz˙bickiReceived: 3 April 2024Revised: 10 May 2024Accepted: 20 May 2024Published: 23 May 2024Copyright: © 2024 by the authors.Licensee MDPI, Basel, Switzerland.This article is an open access articledistributed under the terms andconditions of the Creative CommonsAttribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).International Journal ofEnvironmental Researchand Public HealthArticleSupported Standing and Supported Stepping Devices forChildren with Non-Ambulant Cerebral Palsy:An Interdependence and F-Words FocusGinny S. Paleg 1,* , Sian A. Williams 2,3 and Roslyn W. Livingstone 41 Independent Researcher, Silver Spring, MD 20901, USA2 School of Allied Health, Curtin University, Perth, WA 6009, Australia; sian.williams@curtin.edu.au orsian.williams@auckland.ac.nz3 Liggins Institute, University of Auckland, Auckland 1023, New Zealand4 Occupational Science and Occupational Therapy, Faculty of Medicine, University of British Columbia,Vancouver, BC V6T 2B5, Canada; roslyn.livingstone@ubc.ca* Correspondence: ginny@paleg.comAbstract: Children functioning at Gross Motor Function Classification System (GMFCS) levels IV–Vcannot maintain an aligned standing position or take steps without support. Upright positioning andmobility devices have psycho-social significance for these children and their families, enhancing useof vision, communication, functioning and emotional well-being. Standers and supported steppingdevices facilitate opportunities for biomechanical loading, potentially helping to build and maintainmuscle and bone integrity, and they promote physical development. However, families are oftenrequired to choose between these two devices for their young child. This study aims to synthesizeevidence for use and benefits of both supported standing and stepping devices through the lensof two contemporary theoretical frameworks to support clinical reasoning and implementation.The F-words for childhood development (functioning, family, fitness, fun, friends, future) and theinterdependence-Human Activity Assistive Technology (iHAAT) models were combined to illustratethe complex interactions between the child, family, caregivers, peers and contextual factors whenimplementing standing and stepping devices with children at GMFCS levels IV and V. Supportedstanding and stepping devices provide complementary benefits, and both may be necessary startingat 9–15 months. We propose they both be included ON-Time, along with other age-appropriatepositioning and mobility devices, to promote more equitable developmental opportunities for childrenwith non-ambulant cerebral palsy.Keywords: standing frame; stander; gait trainer; support walker; assistive devices1. IntroductionThe body of evidence regarding therapeutic interventions for cerebral palsy (CP) isquite large, but the vast majority focuses on children who are ambulant (Gross Motor Func-tion Classification System [1] (GMFCS) levels I, II and III) [2]. CP-specific interventions canimprove outcomes in body structure and function (BSF), activity and participation. More-over, the importance of early and age-appropriate interventions has been emphasized [3].Interventions should be child-active and directed, with practice of activities taking placewithin meaningful family or school routines [3]. However, children with different levelsof impairment, topography, movement disorders or concurrent morbidities may responddifferently [4], and there is growing concern that not all children with CP are afforded thesame opportunities for practice or evidence-based interventions [5].Children classified at GMFCS levels IV and V make up between 24.0 and 32.5% [6–8] ofthe CP population (with higher percentages in lower-resourced settings) and are considerednon-ambulant. These children use wheeled mobility devices with physical or poweredInt. J. Environ. Res. Public Health 2024, 21, 669. https://doi.org/10.3390/ijerph21060669 https://www.mdpi.com/journal/ijerphInt. J. Environ. Res. Public Health 2024, 21, 669 2 of 18assistance in most settings [1], and they are more likely to experience secondary muscu-loskeletal impairments, pain and functional limitations [9]. Children with non-ambulantCP never develop efficient quadruped crawling or walking and require assistive devicesfor upright positioning and mobility [1,10].Children at the greatest risk of being non-ambulant can now be identified by 3–5 monthsof age, helping target management and early intervention strategies appropriately. A Gen-eral Movement Assessment Motor Optimality Score (GMA-MOS) below 8 at 2–5 months ofcorrected age and a Hammersmith Infant Neurological Examination (HINE) score below 40between 3 and 24 months of age are the current cut-off scores assisting the identification ofchildren at the highest risk of being classified as GMFCS levels IV or V [11–14]. While a fewchildren functioning at GMFCS level IV may be able to stand briefly without support, mostclassified at GMFCS levels IV/V use devices known as standers, standing frames, standingshells or braces [15]. Children functioning at GMFCS levels IV/V may use supportedstepping devices (also referred to as body support walkers or gait trainers) to move aroundat home or school [16,17].Mobility is a human right and, to be ‘ON-Time’ or age-appropriate developmentally,multiple positioning and mobility modes are needed starting within the first year of life [18].In comparison to prone mobility (crawling), our visual field is significantly expanded inupright positions [19], and the use of an infant walker has been shown to facilitate spatialsearch performance [20]. When supported in an upright position, the expanded visual fieldincreases eye contact with peers and caregivers, potentially enhancing participation andincreasing equity in age-appropriate developmental experiences.Supported standing and stepping devices can promote functioning, fitness and overallhealth, emotional development, inclusion and participation in home and school settingsfor children with non-ambulant CP [21,22]. Development of independent standing orstepping without the devices is not an expectation, and power mobility is the focus forefficient functional mobility for children at GMFCS levels IV/V, especially in communitysettings [3,22,23].From around the age of 12–15 months, muscle volumes of children with CP appearto ‘separate’ from those of typically developing children [24,25]. This is the age whenchildren are typically pulling to stand, playing in a standing position and exploring theirenvironment by stepping. In children with CP, an altered and reduced biomechanicalloading of muscle (related to patterns of reduced standing, walking and physical activity)is proposed as a contributing factor [26–28], with early and consistent activity being theantidote. However, increasing physical activity and decreasing sedentary behavior ischallenging, and few recommendations target, or are appropriate for, children with non-ambulant CP [29].The morphological and structural changes reported in CP muscle in early childhoodmay increase by up to 43% by adolescence [30–32], whilst increases in inter- [33] andintramuscular [34] adiposity [35], excess connective tissue [36,37], and changes in fiber typedistribution and size are also evident. There are strong indications that not only do thesechanges in the muscle increase in individuals classified by higher GMFCS levels [32,38] butthey are also hypothesized to continue to decline with age, with additional degenerativecomplications from chronic stress (resulting from overactive and co-contracting muscles,and movement inefficiencies) as well as from reduced physical activity.Individuals with CP face an earlier and accelerated age-related functional declineand increased risk to cardiometabolic health [39]. Combined with low bone mineraldensity (BMD) [40], adults with CP are at an increased risk of “osteosarcopenia”, theco-existence of both osteoporosis and sarcopenia, which increases the risk of fragilityfractures, causing pain and leading to greater morbidity and mortality as well as highersocioeconomic costs [41]. The morphological and structural properties of a muscle not onlyinfluence its ability to generate strength and support function but they are also importantfor the provision of metabolically active lean tissue available for glucose storage andmetabolism [39], underscoring the important role of muscle for cardiometabolic health.Int. J. Environ. Res. Public Health 2024, 21, 669 3 of 18A scoping review of supported standing device use with children and young adultswith non-ambulant CP [21] summarized and evaluated results from 16 systematic reviews,six clinical guidelines and 37 primary studies. Data from 1101 individuals from 7.2 monthsto 25 years of age were included in experimental, descriptive and qualitative studies. Thefindings of the review highlighted that evidence for the maintenance of BMD and preven-tion of contractures was well supported by experimental studies, with other outcomes (suchas hip stability, bowel function, spasticity management, activities of daily living and grossand fine motor function) being currently supported primarily by quasi-experimental ordescriptive evidence. Across the literature, use of supported standing devices is describedas being influenced by the individual, the device and other factors in the physical, socialand attitudinal environment.In a second scoping review, this time focused on supported stepping device use withchildren and adults with non-ambulant CP. Ref. [22] summarized and critiqued results fromeight systematic or scoping reviews, two clinical guidelines and 59 primary studies. Fifteenof the included 59 primary studies were experimental designs and four were qualitative ormixed-methods, with the remainder being primarily observational or descriptive studiesculminating in data from 705 individuals (ages 9 months to 47.7 years) and 632 therapists.This review concluded that despite limited experimental evidence, included data supportsa positive impact of supported stepping devices on stepping and other physical abilities,as well as on individual self-esteem, independence and autonomy. Lived-experience datasimilarly confirm the influence of the individual’s profile, the type of device and otherenvironmental factors.Although these recent scoping reviews examined what is known about the use ofsupported standing [21] and supported stepping [22] devices, no studies have compared orcontrasted the evidence, outcomes and benefits of these two types of devices, with supportfor clinical reasoning lacking. Both reviews confirmed the influence of environmentalfactors, particularly the device (assistive technology) and the influence of others (socialand attitudinal environment) in the use of supported standing and stepping devices.Despite the importance of using theory to guide research, assist in data interpretation andevaluate intervention choices, the use of theoretical frameworks in assistive technology (AT)outcomes research is extremely limited [42]. Dissemination and implementation science isa growing field, aiming to help bridge the gap between what is known and what is donein practice, as well as to increase equitable access to evidence-based interventions [43].Although systematic or scoping reviews can summarize and evaluate the strength ofevidence for specific interventions, a clinically focused synthesis is needed to supportdecision making and the implementation of these complementary interventions in practice.As summarized in the two scoping reviews, supported standing and stepping devicesafford age-appropriate physical activity, developmental experiences and opportunities. Theuse of both these devices may help to increase and vary opportunities for position change,weight bearing and active movement. In addition, they may help to reduce sedentarybehavior and facilitate participation and engagement in different activities throughout theday [21,22,44]. Unfortunately, in many practice settings, funders do not allow the provisionof both standing and stepping devices ‘ON-Time’ (starting at 9–12 months) and requiretherapists and families to choose one or the other. Synthesizing and comparing the evidence(as established within the two scoping reviews) in relation to contemporary theoreticalframeworks may help to support clinical reasoning and practice implementation.The purpose of this article is to frame and synthesize the best available evidencesupporting the use of standing and stepping devices with children classified as non-ambulant CP through the lens of two contemporary theoretical frameworks: the F-words(functioning, family, fitness, fun, friends and future) for childhood development [45] and theinterdependence-Human Activity Assistive Technology (iHAAT) model [42,46]. Therapistswill be challenged to consider that both standing and stepping devices may be necessary toprovide equitable access to positioning and mobility opportunities ‘ON-Time’ for youngchildren with non-ambulant CP.Int. J. Environ. Res. Public Health 2024, 21, 669 4 of 182. Materials and MethodsThe two scoping reviews of the entire body of evidence related to (1) the use of sup-ported standing devices [21] and (2) supported stepping devices [22] with those classifiedat GMFCS levels IV and V provide comprehensive and up-to-date evidence summaries.Readers are referred to the original publications for details of the search strategy, methodsand results. In this study, results and findings from both reviews were further classified,compared and contrasted in relation to two theoretical frameworks, the F-words andthe iHAAT.Lived-experience data were analyzed in relation to the F-words within the publishedmanuscript [22] by both authors of the review on supported stepping and by all authors ofthe review on supported standing [21] for a conference presentation [47]. Qualitative andquantitative data from both reviews were later compared and contrasted according to theF-words by two authors (GSP and RWL) for another conference presentation [48]. Analysisof data from both reviews in relation to the iHAAT framework was conducted specificallywithin this study. In each case, authors analyzed data independently and agreed on thefindings and synthesis through discussions.2.1. F-Words for Child DevelopmentThe F-words for childhood development [45] (see Figure 1) enhance our understandingof the International Classification of Functioning, Disability and Health (ICF) [49] and area child- and family-friendly way of incorporating ICF concepts into everyday life. Thewords used are meaningful to children and families and facilitate knowledge translation.Functioning combines aspects of activity and participation; fitness relates to BSF; friends isrelated to participation; fun is a combination of personal factors and participation; family isthe most important environmental factor for children; and future, while not included inthe ICF, includes interventions designed to promote future health and development or toprevent known harms [45,50,51].Int. J. Environ. Res. Public Health 2024, 21, x FOR PEER REVIEW 5 of 19 Figure 1. ICF-F-words figure [49,50]. Used with permission of CanChild’s F-words Knowledge Hub: www.canchild.ca/f-words, accessed on 19 May 2024. Copyright 2023, McMaster University. 2.2. Interdependence-Human Activity Assistive Technology (iHAAT) Framework The Human Activity Assistive Technology (HAAT) model is the most longstanding and widely accepted assistive technology framework, illustrating the dynamic interaction between the human (abilities, needs and roles), the activity and the assistive technology or device (AT) within the physical, social and attitudinal context or environment [53]. The activity component includes both activity and participation according to ICF language, and it includes functioning, friends and aspects of fun according to the F-words. Tradi-tionally, assistive devices are prescribed to compensate for lack of ability and promote independence [54]. However, supported standing and stepping devices require caregiver support for successful implementation with children functioning at GMFCS levels IV/V, and all who interact with the child and the device influence their prescription and use [21,22]. There is a continuum from independence to interdependence, and quality of life is influenced by the social circle around all individuals [55]. An interdependence frame em-phasizes the relationships between all people interacting with the assistive device and the environment [54]. Recently, the interdependence frame has been merged with the HAAT model to form the interdependence-Human Activity Assistive Technology (iHAAT) model [42,46]. The iHAAT conceptual framework illustrates how AT may afford increasing partici-pation and engagement in meaningful activities, both for the individual and for others in their circle. An interdependence frame emphasizes “being and doing together” [54] (p. 169). The human(s) are interdependent with the AT and each other, appropriately matched AT promotes participation in desired activities for the human and others within their physical and social context, and all domains of the iHAAT interact to influence qual-ity of life [42,46]. Access (to activities and the environment) and participation may be in-creased, and dependence may be reduced, without the expectation of complete physical or cognitive independence [54]. For children with non-ambulant CP, the goal may be to increase engagement and autonomy, rather than the child being able to complete tasks without assistance. See Figure 2. Fi ure 1. ICF-F-words figure [49,50]. U ed with permiss on of CanChild’s F-words Knowledge Hub:www.canchild.ca/f-words, accessed on 19 May 2024. Copyright 2023, McMaster University.Int. J. Environ. Res. Public Health 2024, 21, 669 5 of 18Under the ICF, assistive devices, such as standing and stepping devices, fall under envi-ronmental modifications, which translates to family within the F-words framework [45,51].However, assistive technology or devices (AT) provide benefits across all F-words [50],and intervention methods may be more clearly linked to F-words based on the goals setor outcomes measured [52]. For example, if a supported standing or stepping device isbeing used to, e.g., maintain BMD or prevent contractures, it may be assigned to fitness; ifit is being used to increase participation in age-appropriate activities with others, it may beassigned to friends, and so on. By associating intervention ingredients with F-words, theycan be matched to child and family goals [50–52].Interventions focused solely on fitness or BSF rarely result in improvements ‘upstream’in the other F-words or ICF domains [2]. However, by addressing child and family goalsand priorities for participation and engagement in meaningful activities, the resultingpractice intensity may lead to fitness benefits [3]. Children and families are more likely touse assistive devices when they increase participation and facilitate the achievement ofage-appropriate goals [50]. A strength of the F-words is the focus on accomplishment andjoy in the moment, rather than a mythical ‘fix’ in the future.2.2. Interdependence-Human Activity Assistive Technology (iHAAT) FrameworkThe Human Activity Assistive Technology (HAAT) model is the most longstandingand widely accepted assistive technology framework, illustrating the dynamic interactionbetween the human (abilities, needs and roles), the activity and the assistive technology ordevice (AT) within the physical, social and attitudinal context or environment [53]. Theactivity component includes both activity and participation according to ICF language, andit includes functioning, friends and aspects of fun according to the F-words. Traditionally,assistive devices are prescribed to compensate for lack of ability and promote indepen-dence [54]. However, supported standing and stepping devices require caregiver supportfor successful implementation with children functioning at GMFCS levels IV/V, and allwho interact with the child and the device influence their prescription and use [21,22].There is a continuum from independence to interdependence, and quality of life isinfluenced by the social circle around all individuals [55]. An interdependence frameemphasizes the relationships between all people interacting with the assistive device andthe environment [54]. Recently, the interdependence frame has been merged with theHAAT model to form the interdependence-Human Activity Assistive Technology (iHAAT)model [42,46].The iHAAT conceptual framework illustrates how AT may afford increasing partic-ipation and engagement in meaningful activities, both for the individual and for othersin their circle. An interdependence frame emphasizes “being and doing together” [54](p. 169). The human(s) are interdependent with the AT and each other, appropriatelymatched AT promotes participation in desired activities for the human and others withintheir physical and social context, and all domains of the iHAAT interact to influence qual-ity of life [42,46]. Access (to activities and the environment) and participation may beincreased, and dependence may be reduced, without the expectation of complete physicalor cognitive independence [54]. For children with non-ambulant CP, the goal may be toincrease engagement and autonomy, rather than the child being able to complete taskswithout assistance. See Figure 2.Int. J. Environ. Res. Public Health 2024, 21, 669 6 of 18Int. J. Environ. Res. Public Health 2024, 21, x FOR PEER REVIEW 6 of 19 Figure 2. iHAAT framework. Used with permission, copyright 2022, Fani Lee [46]. 3. Results Evidence (overall conclusions as well as included study, guideline and review re-sults) from the two scoping reviews [21,22] is compared and contrasted—first in relation to the F-words and then in relation to the iHAAT framework. The reviews on supported standing and stepping are cited where the results are summarized from a number of in-cluded studies or where overall findings/review conclusions are reported. Where state-ments, recommendations or conclusions are specific to the included individual studies, guidelines or reviews, the primary source is cited. Study design/evidence type and study quality are summarized according to the Mixed-Methods Appraisal Tool (MMAT) [56], as rated and reported in the original scoping reviews [21,22]. 3.1. F-Words for Child Development 3.1.1. Functioning Increased mobility (including stepping, walking speed or distance) was the most highly reported outcome (588/705 participants) for supported stepping interventions [22]. Parents also described stepping as more effective in promoting indoor exploration than self-propelling a manual wheelchair [57]. Using a supported stepping device is considered ‘walking’ for many individuals with CP and their families. In personal communication, Peter Rosenbaum has shared that “for most families—and an increasing number of service providers—it is the achievement of ‘functioning’ that is important, not how it is done.” When a child has significantly impaired motor development, there is a shift in goals to a ‘new normal’ that may look very different from ‘typical’ development but is designed to promote development. Just because a child accomplishes their goal differently, does not lessen the value [58]. Increased participation in standing transfers and activities of daily living (ADL) have been measured following both standing [59] and stepping interventions [22]. Increased use of arms and hands for play and self-feeding was the second most highly reported outcome in the review on supported stepping, although only for studies involving hands-free supported stepping devices [22]. Increased attention, use of vision and improved communication outcomes were also widely reported [22]. Improved access to communi-cation devices, increased hand use, self-feeding abilities and independence in play were also reported following the use of standing devices [21]. Improved head and trunk control was highly reported in the review on supported stepping [22], while increased gross Figure 2. iHAAT framework. Used with permission, copyright 2022, Fani Lee [46].3. ResultsEvidence (overall conclusions as well as included study, guideline and review results)from th two scoping reviews [21,22] is compared an contrasted—first i relation to theF-words and then in relation to the iHAAT framework. The reviews on supported sta dingand stepping are cited where the results are summarized from a number of includedstudies or where overall findings/review conclusions are reported. Where statements,recommendations or conclusions are specific to the included individual studies, guidelinesor reviews, the primary source is cited. Study design/evidence type and study quality aresummarized according to the Mixed-Methods Appraisal Tool (MMAT) [56], as rated andreported in the original scoping reviews [21,22].3.1. F-Words for Child D velopment3.1.1. FunctioningIncreased mobility (including stepping, walking speed or distance) was the mosthighly reported outcome (588/705 participants) for supported stepping interventions [22].Parents also described stepping as more effective in promoting indoor exploration thanself-propelling a manual wheelchair [57]. Using a supported stepping device is considered‘walking’ for many individuals with CP and their families. In personal communication,Peter Rosenbaum has shared that “for most families—and an increasing number of serviceprovid rs—it is the achievement of ‘functioning’ that is important, not how it is done”.When a child has s gnificantly impaired motor d velopment, there is a shift in goals to a‘new norm l’ that may look very different fro ‘typical’ evelopment but is designed topromote development. Just because a child accomplishes their goal differently, does notlessen the value [58].Increased participation in standing transfers and activities of daily living (ADL) havebeen measured following both standing [59] and stepping interventions [22]. Increaseduse of arms and hands for play and self-feeding was the second most highly reported out-come in the review on supported stepping, although only for studies involving hands-freesupported stepping devices [22]. Increased attention, use of vision and improved com-munication outcomes were also widely reported [22]. Im roved access to communicationdevices, increased hand use, self-feeding abilities and ind p ndence in play were alsreported following the use of standing devices [21]. Improved head an trunk c ntrol washighly reported in the review on supported stepping [22], while increased gross otorInt. J. Environ. Res. Public Health 2024, 21, 669 7 of 18function was reported following the use of standing devices in a case study [60] and a smallcase series [61].3.1.2. FamilyBoth family and other adults were considered under this F-word (family) [51,52], andboth reviews addressed the impact of the social and attitudinal environment in relation tothe use of standing and stepping devices [21,22]. Parents were ‘mostly’ or ‘very’ satisfiedwith supported stepping devices [16,57,62–64], apart from difficulties with transfers [57],particularly with increasing age of the child [17,65]. Easing caregiving and reducing burdenof care was reported as a benefit for both devices [57,63,66,67].3.1.3. FitnessThe strongest evidence (positive evidence from experimental studies at low risk ofbias) supports the use of supported standing to assist with the maintenance of BMD andthe prevention of contractures [21]. Time weight bearing may be a critical factor for themaintenance of BMD in either standing [68–70] or stepping devices [17], with increasedtime associated with increased density. Improved bowel function has been measured in aqualitative [71] study as well as a feasibility study comparing participants using steppingdevices to participants undergoing a standing program [17]. Two case studies [65,66] andanecdotal reports also suggest a positive impact on bowel function from upright positioningin supported standing.Supported standing is not necessarily a passive activity for children with non-ambulantCP. It may increase heart rate [72] and energy expenditure [73], and it is recommended aspart of a 24 h activity guide to reduce sedentary behavior [74]. However, the potential formobility and overground training would argue that supported stepping devices are likelyto have a greater impact on physical fitness [22], and positive energy expenditure has beenmeasured in response to moderate to vigorous intensity power training in a supportedstepping device [75]. Clinical guidelines recommend overground supported stepping forbone health [76] and for increasing physical fitness in children with non-ambulant CP [3].Evidence for the impact of supported standing on hip health is positive, althoughlower quality, and 1 h weight bearing daily is the most common dosage recommenda-tion [21]. The influence of hip abduction during weight bearing is still unclear, although atleast 10–15 degrees of abduction is recommended [42], due to possible negative effects ofweight bearing with feet together [21]. A pilot randomized controlled trial found improvedhip stability from increased time (up to 1 h) in supported standing despite difficultiesmaintaining adherence in this complex population [77]. No studies have examined theinfluence of supported stepping device use on hip stability, although expert opinion ev-idence supports this outcome [22]. Moreover, the opportunity for actively shifting one’sown weight may benefit bone and joint health [42].Although no studies have examined the impact of supported standing or stepping onmuscle development, decreasing sedentary behavior, increasing activity and facilitatingopportunity for biomechanical loading of the muscle and bone through both supportedstanding and stepping devices could be an effective strategy to build and maintain muscleand bone integrity. Muscle hypertrophy (i.e., increasing the size of the muscle) is typicallytargeted by means of resistant training (where the muscles are working against a force or“load”); however, loading of the muscle for hypertrophic gains (particularly in groups withlow levels of activity) could potentially be met with the person’s own body weight throughstanding or stepping.3.1.4. FunStepping devices can facilitate joy in experiencing independent movement, particularlyfor children who have limited movement abilities [22]. Increased happiness, autonomyand self-efficacy were also frequently mentioned with increased engagement in typicalchildhood experiences, including being naughty, sneaking up on others and runningInt. J. Environ. Res. Public Health 2024, 21, 669 8 of 18away [57,71,78]. Experiences of fun in supported standing were mixed, and a strong themethat emerged in the standing review was that children need choice in where and when tostand. In order to be effective, standing programs must be integrated into age-appropriateand meaningful activities with others that facilitate peer interaction and participation [21].3.1.5. FriendsUpright positioning has psycho-social benefits that impact a child’s self-perceptionand esteem [65]. Being eye-to-eye with peers increased inclusion and participation withothers, and was frequently raised in qualitative studies in relation to both standing andstepping devices [57,65,71,79,80]. The positive impact on children’s self-esteem, sense ofequality and confidence during social interactions was particularly raised in relation to theuse of stepping devices along with the ability to move easily between play activities withothers [22].3.1.6. FutureBoth standing and stepping positively influence physical health, with opportunitiesto increase activity and biomechanical loading of the muscle and bone. These may serveto facilitate change in both the form (i.e., volume and quality) and function of the muscleand bone, which in turn may have a greater role in reducing cardiometabolic risk andfuture health status. Supported standing devices provide more control over body position,alignment and weightbearing [81]; thus, they may be more effective in the maintenance ofBMD and contracture prevention, and they can positively impact hip stability. Supportedstepping devices promote mobility and may be more effective in promoting muscle de-velopment and cardio-respiratory fitness. The impact on psycho-social health of uprightpositioning and mobility should not be overlooked, due to its positive influence on self-esteem, confidence and the perception of others. Increased communication abilities, andthe positive impact on social interaction, attention and learning, may have long-standinginfluences on children’s future opportunities and achievements.Figure 3 compares benefits from using supported standing and supported steppingdevices according to the F-words. Evidence is divided into three categories: experimentalgroup studies; observational group or cross-sectional studies, case series or case reports;and qualitative studies, descriptive evidence from surveys, expert opinion or benefitsdescribed in case series or reports, but not measured using a valid and reliable outcomemeasure. Results are reported from the highest quality studies available for each outcome.Int. J. Environ. Res. Public Health 2024, 21, x FOR PEER REVIEW 9 of 19 Figure 3. F-words comparison of evidence for supported standing and stepping devices (authors’ original graphic). 3.2. iHAAT Conceptual Framework 3.2.1. Human This domain includes the consideration of the child’s profile, needs, abilities (fitness and functioning), goals and desired roles (friends, fun, family and future). With an inter-dependence frame in mind, family (parents and other adult caregivers’) goals, desires, typical routines, physical abilities (for transfers) and ability to use more complex equip-ment should all be considered when choosing between different device types or determin-ing where and when it should be used, as well as what type of device might best meet the goals. In addition, the needs and abilities of other children and adults who will interact with the child while they are using the device should be considered. By enhancing child participation and engagement, supported standing and stepping devices may also in-crease family, sibling and peer interaction (friends), and there may be a reciprocal impact on the perceptions of peers and the wider community (future) [21,22,65]. 3.2.2. Activity The child’s age, stage and life roles influence the types of activities and participation that may be considered appropriate or fun. Activities are influenced by child abilities (fit-ness and functioning), child and family goals and preferences (family, fun and future) as well as others who will engage in the activity with the child (friends and family). The interdependence frame would encourage reflection on the reciprocal interactions and im-pacts on peers, siblings, family and caregivers through engagement in meaningful activi-ties and routines with the child, facilitated by standing and stepping device use. 3.2.3. Assistive Technology Use of and satisfaction with standing and stepping devices is influenced by everyone who interacts with or assists the child in using that device. Prescription is influenced by the human and activity factors previously discussed, all of which have reciprocal interac-tions and interdependence. Device prescription is also influenced by the intended goals and both children and family, peers, caregivers and others are interdependent with the AT [42]. Figure 3. F-words comparison of evidence for supported standing and stepping devices (authors’original graphic).Int. J. Environ. Res. Public Health 2024, 21, 669 9 of 183.2. iHAAT Conceptual Framework3.2.1. HumanThis domain includes the consideration of the child’s profile, needs, abilities (fitnessand functioning), goals and desired roles (friends, fun, family and future). With an in-terdependence frame in mind, family (parents and other adult caregivers’) goals, desires,typical routines, physical abilities (for transfers) and ability to use more complex equipmentshould all be considered when choosing between different device types or determiningwhere and when it should be used, as well as what type of device might best meet thegoals. In addition, the needs and abilities of other children and adults who will interactwith the child while they are using the device should be considered. By enhancing childparticipation and engagement, supported standing and stepping devices may also increasefamily, sibling and peer interaction (friends), and there may be a reciprocal impact on theperceptions of peers and the wider community (future) [21,22,65].3.2.2. ActivityThe child’s age, stage and life roles influence the types of activities and participationthat may be considered appropriate or fun. Activities are influenced by child abilities(fitness and functioning), child and family goals and preferences (family, fun and future)as well as others who will engage in the activity with the child (friends and family). Theinterdependence frame would encourage reflection on the reciprocal interactions andimpacts on peers, siblings, family and caregivers through engagement in meaningfulactivities and routines with the child, facilitated by standing and stepping device use.3.2.3. Assistive TechnologyUse of and satisfaction with standing and stepping devices is influenced by everyonewho interacts with or assists the child in using that device. Prescription is influenced by thehuman and activity factors previously discussed, all of which have reciprocal interactionsand interdependence. Device prescription is also influenced by the intended goals andboth children and family, peers, caregivers and others are interdependent with the AT [42].Fitness and future goals such as maintaining BMD, muscle strength or hip stabilitymay be influenced by weight bearing. Actual weight bearing in standing and steppingdevices varies widely [17,82–84], and it is influenced by device type (multi-position supineversus sit-to-stand) [83], as well as inclination, hip abduction and orientation (prone, supineor upright) [81]. If impact on BMD or muscle is the desired fitness outcome, then it may beimportant to measure actual weight bearing to ensure this goal is being met. In contrast, ifthe desired outcome is inclusion or participation, influencing fun and friends, then otherfactors such as ease of transfer, child- and family-friendly design, color, transportability,accessories (such as a tray), or the ability to position the child to reach desired activities orinteract in chosen routines may be more influential.3.2.4. ContextThe context (physical, social and attitudinal environment) influences and is influencedby the child and their social circle, the assistive device, and the activities and roles desired.The need for caregiver support for success was particularly emphasized in stepping stud-ies [22], while a major theme from the lived-experience supported standing data was thatcollaboration between the child, family, caregivers and therapist is required for successfulstanding programs [21].The physical environment particularly influences the choice of the supported steppingdevice, since some are only appropriate for smooth indoor surfaces, while others havewheels suitable for use on grass, rough ground outdoors, or may be more effective oncarpet or thresholds indoors [85]. Transfers have a major influence on the prescriptionof both standing and stepping devices, and the space for transfers, the child’s ability toprovide assistance, the caregiver’s abilities and the equipment used to facilitate transfers,influence use of these devices [21,22].Int. J. Environ. Res. Public Health 2024, 21, 669 10 of 18Parents’ [86,87], educators’ [88] and therapists’ [89–91] attitudes all influence pre-scription and use of standing devices. Children prioritize comfort in a stander, and thismay correlate with the therapists’ perceptions of good alignment [90]. While therapistshave strong beliefs in the benefits of supported standing for physical health [87], attitudestowards supported stepping devices are mixed. The ‘ON-Time’ mobility framework encour-ages the use of multiple methods of mobility within the first year of life as a child’s right,but some therapists remain concerned that independence and mobility will be achieved atthe cost of ‘normal’ movement patterns [92]. For children with non-ambulant CP, steppingdevices should be used to promote inclusion (functioning, fun and friends) and physicalactivity (Fitness), and these goals should be prioritized over ‘typical’ gait patterns [22].The reciprocal impact of children’s use of supported stepping devices on the attitudes andperceptions of peers and wider societal attitudes [65] reinforces the interdependence frame.3.2.5. Well-BeingFinally, all domains of the iHAAT interact with each other to influence overall qualityof life or well-being. For children, well-being is influenced by overall health, happiness,development and functioning at home, at school and out in the community. The F-wordsapproach also emphasizes the importance of a family-centered holistic, strengths-basedapproach with the overall goal of enhancing well-being [45].See Figure 4 for the application of iHAAT to children at GMFCS levels IV or V usingsupported standing and stepping devices, and relationships between iHAAT componentsand the F-words. Although AT such as supported standing and stepping devices may helpto address all F-words ingredients, the AT is interdependent with the human, activity andcontext domains. For example, a stander may be used to promote BMD (fitness) withinthe human domain, or it may be used to promote self-feeding skills (functioning) withinthe activity domain, or it may be a barrier or facilitator to social participation with peers(friends) within the context domain.Int. J. Environ. Res. Public Health 2024, 21, x FOR PEER REVIEW 11 of 19 Figure 4. An integration of the iHAAT framework and F-words for children with CP (GMFCS levels IV and V) using supported stepping and supported standing devices. Adapted with permission, copyright 2021, Fani Lee [42]. 4. Discussion Both standing and stepping devices are well tolerated by children with non-ambulant CP, with an average dosage of 60 min, 5–7 days a week reported for both devices. There is a considerable overlap between the benefits and outcomes of standing and stepping devices, although both increase participation in age-appropriate activities with others. Standers may provide greater benefits for BMD, contracture prevention and hip stability, while stepping devices may provide more benefits for physical fitness, psycho-social, communication and emotional development due to the benefits of self-initiated mobility. Around twenty years ago, it was a popular concept that invoking the central pattern generator for stepping would improve gait outcomes in adults with stroke, brain injury or spinal cord injury (SCI). However, large-scale randomized controlled studies failed to support this concept [93]. Today, we understand that reflexes cannot be ‘integrated’ or turned into volitional movements, and the idea of using the central pattern generator for stepping is absent from the contemporary literature. Current clinical practice guidelines for improving walking speed and distance in adults with stroke, brain injury and SCI rec-ommend task-specific overground walking training as being more effective than treadmill or robotic training, particularly for individuals who are at least 6 months post-injury, for the purposes of improving walking speed and distance [93]. The most recent (2017) Cochrane review of treadmill training for young children mainly included studies of children with Down syndrome, while only two studies focused on children with CP. A small increase in walking speed was measured for children with developmental delays, and improved motor skills were measured for children at GMFCS levels I or II, but no studies included children at GMFCS levels IV or V [94]. In the CP literature, there has been a shift towards the use of robotic gait devices. However, for chil-dren with non-ambulant CP, no significant benefits have been measured, in comparison to children using a combination of treadmill training with overground training in a sup-ported stepping device [95]. An earlier study demonstrated that walking speed and Figure 4. An integration of the iHAAT framework and F-words for children with CP (GMFCS levelsIV and V) usi g supported stepping and supported standing devices. Adapted with permission,copyright 2021, Fani Lee [42].Int. J. Environ. Res. Public Health 2024, 21, 669 11 of 184. DiscussionBoth standing and stepping devices are well tolerated by children with non-ambulantCP, with an average dosage of 60 min, 5–7 days a week reported for both devices. There is aconsiderable overlap between the benefits and outcomes of standing and stepping devices,although both increase participation in age-appropriate activities with others. Standers mayprovide greater benefits for BMD, contracture prevention and hip stability, while steppingdevices may provide more benefits for physical fitness, psycho-social, communication andemotional development due to the benefits of self-initiated mobility.Around twenty years ago, it was a popular concept that invoking the central patterngenerator for stepping would improve gait outcomes in adults with stroke, brain injuryor spinal cord injury (SCI). However, large-scale randomized controlled studies failed tosupport this concept [93]. Today, we understand that reflexes cannot be ‘integrated’ orturned into volitional movements, and the idea of using the central pattern generator forstepping is absent from the contemporary literature. Current clinical practice guidelines forimproving walking speed and distance in adults with stroke, brain injury and SCI recom-mend task-specific overground walking training as being more effective than treadmill orrobotic training, particularly for individuals who are at least 6 months post-injury, for thepurposes of improving walking speed and distance [93].The most recent (2017) Cochrane review of treadmill training for young childrenmainly included studies of children with Down syndrome, while only two studies focusedon children with CP. A small increase in walking speed was measured for children withdevelopmental delays, and improved motor skills were measured for children at GMFCSlevels I or II, but no studies included children at GMFCS levels IV or V [94]. In the CPliterature, there has been a shift towards the use of robotic gait devices. However, for chil-dren with non-ambulant CP, no significant benefits have been measured, in comparison tochildren using a combination of treadmill training with overground training in a supportedstepping device [95]. An earlier study demonstrated that walking speed and enduranceincreased in children with CP (GMFCS levels III and IV) who trained overground usingwalkers and supported stepping devices in comparison to those treadmill training [96].Drawing upon the key intervention ingredients of child-active and task-specific prac-tice [3], intervention approaches seeking to improve walking or stepping for children withCP might opt to incorporate functional overground walking whereby the active use of theplantar flexors and hip and knee extensors is required to move forward. When stepping ona treadmill, there are some limitations as to its ‘child-active’ and ‘task-specific’ ingredients.For example, while the child is required to activate the hip and knee flexors to step forwardon a treadmill (unless assisted by an adult), the leg is pulled back passively. Also, whiletreadmill training might be ideal for fitness benefits, such as increasing heart rate and stepcount, it does not offer the visual and sensory experience of overground training nor thepotential for enhancing participation and engagement with friends.Children with non-ambulant CP have increased stepping, achievement of functionalgoals and improved gross motor skill following intensive locomotor training where theyparticipated in a combination of partial body weight support treadmill training immediatelyfollowed by practice overground [95]. This suggests that the ‘warm-up’ on the treadmillmay be beneficial for some children as preparation for practice stepping overground. Ifintensive blocks of treadmill or robotic training are chosen as the family’s preference, theyshould also be accompanied by overground stepping to promote functioning in real-lifecontexts and activities.It may also be argued that, in comparison to supported stepping devices, powermobility promotes more efficient and effective mobility for children with non-ambulantCP [23,97]. While this is certainly true for larger spaces, such as in school, outdoors andfor distance and community mobility, there are limitations with power mobility in smallerhomes and early childhood settings [98,99]. There are few developmentally appropriatedevices that are sufficiently maneuverable and safe for use in indoor settings with otheryoung children [99–102]. Children may also have difficulty reaching toys or performingInt. J. Environ. Res. Public Health 2024, 21, 669 12 of 18activities from the seated position in a powered wheelchair [103], while children usinghands-free stepping devices have increased use of arms and hands as well as engagementin play and participation with others [22,78,104].In line with the need to decrease sedentary behavior in children with non-ambulantCP, the ON-Time mobility framework would also suggest that multiple modes of mobilityshould be introduced, starting by 12 months of age. Individuals with non-ambulant CP arereported to spend long periods of time in lying and sitting positions, and they have limitedabilities to move without support [105]. Standing at least one hour daily, with an additionalhour of supported stepping, may offer enough variability to counter the negative effects ofthe prolonged time spent in a sitting position. A case report of twins functioning at GMFCSlevel V demonstrated the feasibility of ON-Time introduction of adaptive seating, standing,stepping and early power mobility devices, with a positive impact on all F-words [106].This study also reinforced the interdependence between parents, children and siblings, andthe impact that assistive device use may have on family functioning and goals.The use of supported standing, supported stepping and power mobility devices hasalso been shown to be feasible for a group of young children, 18 months to 7 years, withCP. While not all children had both standing and stepping devices, more than half of thechildren functioning at GMFCS levels IV or V (19/34) used standing, stepping and powermobility devices concurrently for at least 6 months. A key finding was that the introductionof power mobility did not decrease the use of stepping devices for children at GMFCSlevels III, IV or V [107]. Of the 14 children at GMFCS level V who used supported steppingdevices, 8/14 maintained and 6/14 increased their time in stepping devices following theintroduction of power mobility. Since these children require support to attain or maintainupright positions, parents may have found the variety of complementary positioning andmobility options useful for increasing their functioning and fun.Powered ride-on toy studies have demonstrated the feasibility of using these devices instanding positions for infants with Down syndrome [108]. For children with developmentaldelays, including CP, social skills may be increased by training in a standing position due toan increased visual field of view [109]. However, mobility and social skills have been shownto increase following structured powered ride-on car training in various combinations ofsitting and standing positions [110]. A more intense intervention dosage may be requiredfor children with severe disabilities, such as those with non-ambulant CP, and the use of avariety of positioning and mobility devices within meaningful and natural routines may beone way to achieve this.However, assistive devices are expensive, and this may be a significant barrier withregard to the use of multiple devices in many settings. For the smallest children (interms of height and weight), typical baby equipment may be used to support standingand stepping in the home and child care environment (e.g., exersaucers or ride-on toys).Bracing, splints or locally sourced materials (paper, plaster, cardboard, wood, etc.) can alsobe used to provide sufficient time in upright positions as alternatives to more expensivedurable medical equipment [111–113]. Basic wheeled walkers have also been successfullyadapted with low-cost materials to create hands-free supported stepping devices suitablefor children with non-ambulant cerebral palsy in lower-resourced settings [62].In the United States (US), the Individuals with Disabilities Education Act (IDEA)ensures free appropriate public education (FAPE) for children with disabilities. This isprovided through Individualized Family Service Plans (IFSP) for infants and toddlersas well as Individualized Education Plans (IEP) for school-aged children. Under theseprograms, assistive technology necessary for FAPE and/or to address IFSP or IEP goalsmust be provided, maintained, and reassessed yearly; moreover, devices must be availablefor children to use at home over the weekends and holidays. Therefore, in the US, it may bea matter of the law for supported standing and stepping devices to be provided to addressfunctioning, fitness, fun, friends and future goals for children with mobility limitations.In other settings with publicly available funding or loan programs for positioning andmobility devices, the use of multiple positioning and mobility devices may be influencedInt. J. Environ. Res. Public Health 2024, 21, 669 13 of 18more by attitudes. Standers or standing frames are often considered first, and steppingdevices are not considered until older ages. This hierarchical approach is outdated, anddoes not consider that children typically pull to stand and begin to step in very closesuccession. It is known that adults interact differently with children who are standing andstepping, in comparison to those who are lying or sitting [114]. In order to be providedwith equitable developmental opportunities, children with non-ambulant CP need multipleON-Time positioning and mobility opportunities, starting within the first year of life.LimitationsThis study synthesized the results of scoping reviews conducted by two of the authors,raising questions of possible bias in the selection of citations. However, these reviewswere systematically conducted, with protocols and inclusion criteria being registered apriori. They included hand searching and grey literature, in addition to extensive databasesearches. As with any review, it is possible that unpublished studies, or those conducted inother locations, may have been missed. However, these reviews are the most current andcomprehensive evidence sources available in relation to the use of supported standing andstepping interventions for children with non-ambulant CP.Evidence level was descriptively summarized in Figure 3 to assist with knowledgetranslation of scoping review results through the lens of the F-words framework. Resultsfrom the highest evidence level and lowest risk of bias/highest quality studies wereincluded where possible. Group experimental, observational and qualitative study evidencewas mainly moderate or high quality, other than research on hip stability, which is stilllimited, as indicated in Section 3. This manuscript is not a scoping or systematic review,and readers are directed to the two original review publications [21,22] for details regardingevidence level, quality and risk of bias analyses.Two different theoretical frameworks were used in the analysis of this evidence tocreate an integrated model, which is open to discussion. However, we feel that thesecomplement each other with their different emphases. Although the F-words frameworksupports a holistic approach to physical activity and rehabilitation interventions, fewarticles have applied it to interventions for children at GMFCS levels IV or V, and it is notfocused on AT. In contrast, the i-HAAT is an AT-specific framework, and it additionallyplaces focus on interdependence, which is critical when considering children with non-ambulant CP.5. ConclusionsSupported standing and stepping devices should be introduced within the first year oflife to promote functioning, family, fitness, fun, friends and future goals as part of ON-Timemobility. The interdependence frame encourages reflection on the reciprocal interactionsbetween the family, caregivers, peers and wider society interacting with children using sup-ported standing and stepping devices to engage and increase their autonomy in meaningfulactivities and roles within the physical, social and attitudinal environment or context.This study, and the integrated iHAAT and F-words model, challenge therapists to con-sider that young children at GMFCS levels IV and V should have opportunities to engagein both supported standing and stepping, in addition to power mobility. Standing andstepping devices afford weightbearing and mobility, that is medically and developmentallynecessary. Multiple modes of upright positioning and mobility are needed to provideequitable developmental opportunities for young children with non-ambulant CP.Author Contributions: Conceptualization, methodology and analysis, G.S.P., S.A.W. and RWL.;writing—original draft preparation, R.W.L.; writing—review and editing, G.S.P. and S.A.W.; visu-alization, G.S.P., S.A.W. and R.W.L. All authors have read and agreed to the published version ofthe manuscript.Funding: This research received no external funding.Institutional Review Board Statement: Not applicable.Int. J. Environ. Res. Public Health 2024, 21, 669 14 of 18Informed Consent Statement: Not applicable.Data Availability Statement: The data used in this study are contained within the article.Acknowledgments: We would like to thank Peter Rosenbaum, Rachel Teplicky and CanChild forproviding permission to us to include the ICF-F-words figures displayed in this article. Moreover, weare grateful to Fani Lee for her willingness to share her research regarding iHAAT development andfor providing permission to include, and adapt the iHAAT framework figures.Conflicts of Interest: S.A.W. and R.W.L. declare no conflicts of interest. G.S.P. has worked as aneducational consultant for Prime Engineering, a manufacturer of standing and stepping devices.Prime Engineering did not provide funding for this study and had no inputs regarding the content orwriting of this manuscript.References1. Palisano, R.J.; Rosenbaum, P.; Bartlett, D.; Livingston, M.H. Content validity of the expanded and revised Gross Motor FunctionClassification System. Dev. Med. Child. Neurol. 2008, 50, 744–750. [CrossRef] [PubMed]2. Novak, I.; Morgan, C.; Fahey, M.; Finch-Edmonson, M.; Galea, C.; Hines, A.; Langdon, K.; McNamara, M.; Paton, M.C.B.; Popat,H.; et al. State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children withCerebral Palsy. Curr. Neurol. Neurosci. Rep. 2020, 20, 3. [CrossRef] [PubMed]3. Jackman, M.; Sakzewski, L.; Morgan, C.; Boyd, R.N.; Brenna, S.E.; Langdon, K.; Toovey, R.A.M.; Greaves, S.; Thorley, M.; Novak, I.Interventions to improve physical function for children and young people with cerebral palsy: International clinical practiceguideline. Dev. Med. Child. Neurol. 2022, 64, 536–549. [CrossRef] [PubMed]4. Rosenbaum, P. Cerebral palsy: What parents and doctors want to know. Bmj 2003, 326, 970–974. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1125882/pdf/970.pdf (accessed on 19 May 2024). [CrossRef] [PubMed]5. Bailes, A.F.; Greve, K.; Long, J.; Kurowski, B.G.; Vargus-Adams, J.; Aronow, B.; Mitelpunkt, A. Describing the Delivery ofEvidence-Based Physical Therapy Intervention to Individuals with Cerebral Palsy. Pediatr. Phys. Ther. 2021, 33, 65–72. [CrossRef][PubMed]6. Hollung, S.J.; Hägglund, G.; Gaston, M.S.; Seid, A.K.; Lydersen, S.; Alriksson-Schmidt, A.I.; Andersen, G.L. Point prevalence andmotor function of children and adolescents with cerebral palsy in Scandinavia and Scotland: A CP-North study. Dev. Med. Child.Neurol. 2021, 63, 721–728. [CrossRef] [PubMed]7. Reid, S.M.; Carlin, J.B.; Reddihough, D.S. Using the Gross Motor Function Classification System to describe patterns of motorseverity in cerebral palsy. Dev. Med. Child. Neurol. 2011, 53, 1007–1012. [CrossRef] [PubMed]8. McIntyre, S.; Badawi, N.; Balde, I.; Goldsmith, S.; Karlsson, P.; Novak, I.; Ostojik, K.; Smithers-Sheedy, H.; Waight, E.; Murray, N.;et al. Australian Cerebral Palsy Register Report. 2018. Available online: https://cpregister.com/wp-content/uploads/2019/02/Report-of-the-Australian-Cerebral-Palsy-Register-Birth-Years-1995-2012.pdf (accessed on 20 January 2024).9. Bartlett, D.; Hanna, S.; Avery, L.; Stevenson, R.; Galuppi, B. Correlates of decline in gross motor capacity in adolescents withcerebral palsy in Gross Motor Function Classification System levels III to V: An exploratory study. Dev. Med. Child. Neurol. 2010,52, e155–e160. [CrossRef] [PubMed]10. Bolton, M.; Donohoe, M. Ambulatory assistive devices for children and youth with cerebral palsy. In Cerebral Palsy; Miller, F.,Bachrach, S.J., Lennon, N., O’Neil, M.E., Eds.; Springer Nature: Berlin/Heidelberg, Germany, 2020; pp. 2963–2975. [CrossRef]11. Maitre, N.L.; Chorna, O.; Romeo, D.M.; Guzzetta, A. A High-Risk Infant Follow-Up Program. Pediatr. Neurol. 2016, 65, 31–38.[CrossRef]12. Einspieler, C.; Bos, A.F.; Krieber-Tomantschger, M.; Alvarado, E.; Barbosa, V.M.; Bertoncelli, N.; Burger, M.; Chorna, O.; Del Secco,S.; DeRegnier, R.A.; et al. Cerebral Palsy: Early Markers of Clinical Phenotype and Functional Outcome. J. Clin. Med. 2019, 8, 1616.[CrossRef]13. Einspieler, C.; Marschik, P.B.; Pansy, J.; Scheuchenegger, A.; Krieber, M.; Yang, H.; Kornacka, M.K.; Rowinska, E.; Soloveichik, M.;Bos, A.F. The general movement optimality score: A detailed assessment of general movements during preterm and term age.Dev. Med. Child. Neurol. 2016, 58, 361–368. [CrossRef] [PubMed]14. Romeo, D.M.; Ricci, D.; Brogna, C.; Mercuri, E. Use of the Hammersmith Infant Neurological Examination in infants with cerebralpalsy: A critical review of the literature. Dev. Med. Child. Neurol. 2016, 58, 240–245. [CrossRef] [PubMed]15. Rodby-Bousquet, E.; Hägglund, G. Sitting and standing performance in a total population of children with cerebral palsy: Across-sectional study. BMC Musculoskelet. Disord. 2010, 11, 131. [CrossRef]16. Wright, F.V.; Belbin, G.; Slack, M.; Jutai, J. An evaluation of the David Hart Walker Orthosis: A new assistive device for childrenwith Cerebral Palsy. Physiother. Can. 1999, 51, 280–291.17. Eisenberg, S.; Zuk, L.; Carmeli, E.; Katz-Leurer, M. Contribution of stepping while standing to function and secondary conditionsamong children with cerebral palsy. Pediatr. Phys. Ther. 2009, 21, 79–85. [CrossRef] [PubMed]18. Sabet, A.; Feldner, H.; Tucker, J.; Logan, S.W.; Galloway, J.C. ON Time Mobility: Advocating for Mobility Equity. Pediatr. Phys.Ther. 2022, 34, 546–550. [CrossRef] [PubMed]Int. J. Environ. Res. Public Health 2024, 21, 669 15 of 1819. Kretch, K.S.; Franchak, J.M.; Adolph, K.E. Crawling and walking infants see the world differently. Child. Dev. 2014, 85, 1503–1518.[CrossRef] [PubMed]20. Kermoian, R.; Campos, J.J. Locomotor experience: A facilitator of spatial cognitive development. Child. Dev. 1988, 59, 908–917.Available online: http://www.ncbi.nlm.nih.gov/pubmed/3168629 (accessed on 19 May 2024). [CrossRef] [PubMed]21. McLean, L.; Paleg, G.; Livingstone, R. Supported-standing interventions for children and young adults with non-ambulantcerebral palsy: A scoping review. Dev. Med. Child. Neurol. 2023, 65, 754–772. [CrossRef]22. Livingstone, R.W.; Paleg, G.S. Use of overground supported-stepping devices for non-ambulant children, adolescents, and adultswith cerebral palsy: A scoping review. Disabilities 2023, 3, 165–195. [CrossRef]23. Livingstone, R.; Paleg, G. Practice considerations for the introduction and use of power mobility for children. Dev. Med. Child.Neurol. 2014, 56, 210–221. [CrossRef] [PubMed]24. Willerslev-Olsen, M.; Choe Lund, M.; Lorentzen, J.; Barber, L.; Kofoed-Hansen, M.; Nielsen, J.B. Impaired muscle growth precedesdevelopment of increased stiffness of the triceps surae musculotendinous unit in children with cerebral palsy. Dev. Med. Child.Neurol. 2018, 60, 672–679. [CrossRef] [PubMed]25. Herskind, A.; Ritterband-Rosenbaum, A.; Willerslev-Olsen, M.; Lorentzen, J.; Hanson, L.; Lichtwark, G.; Nielsen, J.B. Musclegrowth is reduced in 15-month-old children with cerebral palsy. Dev. Med. Child. Neurol. 2016, 58, 485–491. [CrossRef] [PubMed]26. Shortland, A. Muscle deficits in cerebral palsy and early loss of mobility: Can we learn something from our elders? Dev. Med.Child. Neurol. 2009, 51 (Suppl. S4), 59–63. [CrossRef] [PubMed]27. Verschuren, O.; Smorenburg, A.R.P.; Luiking, Y.; Bell, K.; Barber, L.; Peterson, M.D. Determinants of muscle preservation inindividuals with cerebral palsy across the lifespan: A narrative review of the literature. J. Cachexia Sarcopenia Muscle 2018, 9,453–464. [CrossRef] [PubMed]28. Handsfield, G.G.; Williams, S.; Khuu, S.; Lichtwark, G.; Stott, N.S. Muscle architecture, growth, and biological Remodelling incerebral palsy: A narrative review. BMC Musculoskelet. Disord. 2022, 23, 233. [CrossRef] [PubMed]29. Ganz, F.; Hammam, N.; Pritchard, L. Sedentary behavior and children with physical disabilities: A scoping review. Disabil.Rehabil. 2021, 43, 2963–2975. [CrossRef] [PubMed]30. Handsfield, G.G.; Meyer, C.H.; Abel, M.F.; Blemker, S.S. Heterogeneity of muscle sizes in the lower limbs of children with cerebralpalsy. Muscle Nerve 2016, 53, 933–945. [CrossRef] [PubMed]31. Reid, S.L.; Pitcher, C.A.; Williams, S.A.; Likari, M.K.; Valentine, J.P.; Shipman, P.J.; Elliott, C.M. Does muscle size matter? therelationship between muscle size and strength in children with cerebral palsy. Disabil. Rehabil. 2015, 37, 579–584. [CrossRef]32. Pitcher, C.A.; Elliott, C.M.; Valentine, J.P.; Stannage, K.; Williams, S.A.; Shipman, P.J.; Reid, S.L. Muscle morphology of the lowerleg in ambulant children with spastic cerebral palsy. Muscle Nerve 2018, 58, 818–823. [CrossRef]33. Johnson, D.L.; Miller, F.; Subramanian, P.; Modlesky, C.M. Adipose Tissue Infiltration of Skeletal Muscle in Children with CerebralPalsy. J. Pediatr. 2009, 154, 715–720. [CrossRef] [PubMed]34. Noble, J.J.; Charles-Edwards, G.D.; Keevil, S.F.; Lewis, A.P.; Gough, M.; Shortland, A.P. Intramuscular fat in ambulant youngadults with bilateral spastic cerebral palsy. BMC Musculoskelet. Disord. 2014, 15, 236. [CrossRef] [PubMed]35. Marbini, A.; Ferrari, A.; Cioni, G.; Bellanova, M.F.; Fusco, C.; Gemignani, F. Immunohistochemical study of muscle biopsy inchildren with cerebral palsy. Brain Dev. 2002, 24, 63–66. [CrossRef]36. Smith, L.R.; Lee, K.S.; Ward, S.R.; Chambers, H.G.; Lieber, R.L. Hamstring contractures in children with spastic cerebral palsyresult from a stiffer extracellular matrix and increased in vivo sarcomere length. J. Physiol. 2011, 589, 2625–2639. [CrossRef][PubMed]37. Rose, J.; Haskell, W.; Gamble, J.; Hamilton, R.; Brown, D.; Rinsky, L. Muscle pathology and clinical measures of disability inchildren with cerebral palsy. J. Orthop. Res. 1994, 12, 758–768. [CrossRef] [PubMed]38. Massaad, A.; Assi, A.; Bakouny, Z.; Bizdikian, A.J.; Skalli, W.; Ghanem, I. Alterations of treatment-naïve pelvis and thigh musclemorphology in children with cerebral palsy. J. Biomech. 2019, 82, 178–185. [CrossRef] [PubMed]39. Peterson, M.D.; Gordon, P.M.; Hurvitz, E.A. Chronic disease risk among adults with cerebral palsy: The role of prematuresarcopoenia, obesity and sedentary behaviour. Obes. Rev. 2013, 14, 171–182. [CrossRef] [PubMed]40. Won, J.H.; Jung, S.H. Bone Mineral Density in Adults with Cerebral Palsy. Front. Neurol. 2021, 12, 733322. [CrossRef] [PubMed]41. Edwards, M.H.; Dennison, E.M.; Aihie Sayer, A.; Fielding, R.; Cooper, C. Osteoporosis and sarcopenia in older age. Bone 2015, 80,126–130. [CrossRef]42. Lee, F.; Balcazar, F.; Hsieh, K.; Sposato Bonfiglio, B.; Parker Harris, S.; Feldner, H.A. Factors impacting community living outcomesamong former long-term nursing home residents using the interdependence-Human Activity Assistive Technology (iHAAT)model. Assist. Technol. 2024, 1–10. [CrossRef]43. Becker, S.J.; DeClemente-Bosco, K.; Scott, K.; Helseth, S.A.; Patel-Syed, Z.; Li, D.H. The “D&I Bridge”: Introducing a teaching toolto define the D, the I, and the why. Implement. Sci. Comm. 2024, 5, 18. [CrossRef] [PubMed]44. Paleg, G.; Livingstone, R. Evidence-informed clinical perspectives on postural management for hip health in children and adultswith non-ambulant cerebral palsy. J. Pediatr. Rehabil. Med. 2022, 15, 39–48. [CrossRef] [PubMed]45. Rosenbaum, P.; Gorter, J.W. The “F-words” in childhood disability: I swear this is how we should think! Child. Care Health Dev.2012, 38, 457–463. [CrossRef]Int. J. Environ. Res. Public Health 2024, 21, 669 16 of 1846. Lee, F.N.; Feldner, H.A.; Hsieh, K.; Balcazar, F.; Bonfiglio, B.S.; Parker, S. The interdependence-Human Activity AssistiveTechnology Model (i-HAAT): A contemporary conceptual approach to assistive technology outcomes research. In Proceedings ofthe RESNA Annual Conference 2022, Washington, DC, USA (Online), 13–15 July 2022; Available online: https://www.resna.org/sites/default/files/conference/2022/ServiceDeliveryandOutcomes/85_Lee/85_Lee.pdf (accessed on 20 January 2024).47. McLean, L.; Paleg, G.; Livingstone, R. Stand up for participation and function. In Proceedings of the 38th International SeatingSymposium, Pittsburgh, PA, USA, 13–15 April 2023. [CrossRef]48. Paleg, G.; Livingstone, R. Standing and stepping for participation and engagement with non-ambulant cerebral palsy. InProceedings of the Nordic Seating Symposium 2023, Stockholm, Sweden (Online), 8–10 February 2023.49. World Health Organization. International Classification of Functioning, Disability and Health (ICF); World Health Organization:Geneva, Switzerland, 2001.50. Bradbury, M.; Bennison, E.; Mason, H.; Gregory, J. Tools for participation: Living aids and the F-words for childhood development.Paediatr. Child Health 2021, 31, 352–358. [CrossRef]51. de Campos, A.C.; Hidalgo Robles, A.; Longo, E.; Shrader, C.; Paleg, G. Scoping review of early interventions for young childrenclassified as Gross Motor Function Classification System (GMFCS) IV and V. Dev. Med. Child. Neurol. 2024, 66, 41–51. [PubMed]52. Longo, E.; Monteiro, R.; Hidalgo-Robles, A.; Paleg, G.; Shrader, C.; de Campos, A.C. Intervention ingredients and F-words inearly intervention for children with cerebral palsy functioning at GMFCS IV and V: A scoping review protocol. Front. Rehabil. Sci.2023, 4, 1110552. [CrossRef] [PubMed]53. Giesbrecht, E. Application of the Human Activity Assistive Technology model for occupational therapy research. Aust. Occup.Ther. J. 2013, 60, 230–240. [CrossRef] [PubMed]54. Bennett, C.L.; Brady, E.; Branham, S.M. Interdependence as a frame for assistive technology research and design. In Proceedingsof the 20th International ACM SIGACCESS Conference on Computers and Accessibility, Galway, Ireland, 22–24 October 2018; pp.161–173. [CrossRef]55. White, G.W.; Simpson, J.L.; Gonda, C.; Ravesloot, C.; Coble, Z. Moving from independence to interdependence: A conceptualmodel for better understanding community participation of centers for independent living consumers. J. Disabil. Policy Stud.2010, 20, 233–240. [CrossRef]56. Hong, Q.N.; Pluye, P.; Fàbregues, S.; Bartlett, G.; Boardman, F.; Cargo, M.; Dagenais, P.; Gagnon, M.-P.; Griffiths, F.; Nico-lau, B.; et al. Mixed Methods Appraisal Tool (MMAT), Version 2018. User Guide. McGill. 2018, pp. 1–11. Available on-line: http://mixedmethodsappraisaltoolpublic.pbworks.com/w/file/fetch/127916259/MMAT_2018_criteria-manual_2018-08-01_ENG.pdf (accessed on 20 January 2024).57. Paananen, L. Ihastuttaako Vai Vihastuttaako? Kävelyn Apuvälineeseen. Master’s Thesis, Jamk University of Applied Sci-ences, Jyväskylä, Finland, 2009. Available online: https://www.theseus.fi/bitstream/handle/10024/6662/Paananen_Laila.pdf?sequence=1&isAllowed=y (accessed on 20 January 2024).58. Rosenbaum, P. To enhance function, promote children’s development. Dev. Med. Child. Neurol. 2021, 63, 628. [CrossRef]59. Gibson, S.K.; Sprod, J.A.; Maher, C.A. The use of standing frames for contracture management for nonmobile children withcerebral palsy. Int. J. Rehabil. Res. 2009, 32, 316–323. [CrossRef]60. Audu, O.; Daly, C. Standing activity intervention and motor function in a young child with cerebral palsy: A case report.Physiother. Theory Pract. 2017, 33, 162–172. [CrossRef] [PubMed]61. George, F.K. The importance of static and dynamic posture: How making static equipment dynamic may improve movement andfunction of children with neurological impairment—A retrospective service evaluation. Assoc. Paediatr. Chart. Physiother. J. 2018,9, 56–62.62. Sharma, M.; Bajracharya, S. Low cost modified reverse walker to assist children with cerebral palsy. RGUHS J. Allied Health Sci.2021, 1, 18–24. Available online: https://journalgrid.com/view/article/rjahs/37 (accessed on 20 January 2024).63. Wright, F.V.; Jutai, J.W. Evaluation of the longer-term use of the David Hart Walker Orthosis by children with cerebral palsy: A3-year prospective evaluation. Disabil. Rehabil. Assist. Technol. 2006, 1, 155–166. [CrossRef] [PubMed]64. Martín Gómez, M.; Laguna-Mena, C.; Martín-Maroto, M.; Echevarria-Ulloa, M.; Dumitrescu, A.; Arroyo-Riaño, M. Evaluationand follow-up of NF-Walker technical aid during the transition to adult life. Dev. Med. Child. Neurol. 2021, 63 (Suppl. S2), 42.[CrossRef]65. McKeever, P.; Rossen, B.E.; Scott, H.; Robinson-Vincent, K.; Wright, V. The significance of uprightness: Parents’ reflections onchildren’s responses to a hands-free walker for children. Disabil. Soc. 2013, 28, 380–392. [CrossRef]66. Capati, V.; Covert, S.Y.; Paleg, G. Stander use for an adolescent with cerebral palsy at GMFCS level V with hip and kneecontractures. Assist. Technol. 2020, 32, 335–341. [CrossRef] [PubMed]67. Rivi, E.; Filippi, M.; Fornasari, E.; Mascia, M.T.; Ferrari, A.; Costi, S. Effectiveness of standing frame on constipation in childrenwith cerebral palsy: A single-subject study. Occup. Ther. Int. 2014, 21, 115–123. [CrossRef]68. Caulton, J.M. A randomised controlled trial of standing programme on bone mineral density in non-ambulant children withcerebral palsy. Arch. Dis. Child. 2004, 89, 131–135. [CrossRef] [PubMed]69. Han, E.Y.; Choi, J.H.; Kim, S.H.; Im, S.H. The effect of weight bearing on bone mineral density and bone growth in children withcerebral palsy. Medicine 2017, 96, 16–19. [CrossRef]Int. J. Environ. Res. Public Health 2024, 21, 669 17 of 1870. Shin, M.J.; Shin, Y.B.; Ko, H.-Y.; Sohn, H.J.; Chang, J.H.; Kim, S.Y.; Kim, S.N.; Kim, W.; Kim, I.N. Effect on the bone mineral densityaccording to weight-bearing exercise in children with spastic quadriplegic cerebral palsy: A preliminary study. Ann. Rehabil. Med.2010, 34, 622–627.71. Rodríguez-Costa, I.; De la Cruz-López, I.; Fernández-Zárate, I.; Maldonado-Bascón, S.; Lafuente-Arroyo, S.; Nunez-Nagy, S.Benefits of a low-cost walking device in children with cerebral palsy: A qualitative study. Int. J. Environ. Res. Public Health 2021,18, 2808. [CrossRef]72. Israeli-Mendlovic, H.; Mendlovic, J.; Katz-Leurer, M. Heart rate and heart rate variability parameters at rest, during activity andpassive standing among children with cerebral palsy GMFCS IV-V. Dev. Neurorehabil. 2014, 17, 398–402. [CrossRef]73. Verschuren, O.; Peterson, M.D.; Leferink, S.; Darrah, J. Muscle activation and energy-requirements for varying postures inchildren and adolescents with cerebral palsy. J. Pediatr. 2014, 165, 1011–1016. [CrossRef]74. Verschuren, O.; Hulst, R.Y.; Voorman, J.; Pillen, S.; Luitwieler, N.; Dudink, J.; Gorter, J.W. 24-Hour activity for children withcerebral palsy: A clinical practice guide. Dev. Med. Child. Neurol. 2020, 63, 54–59. [CrossRef]75. Smati, S.; Pouliot-Laforte, A.; Chevalier, M.; Lemay, M.; Ballaz, L. Effect of power training on locomotion capacities in childrenwith cerebral palsy with GMFCS level III–IV. Disabil. Rehabil. 2022, 45, 2329–2335. [CrossRef]76. Gannotti, M.E.; Liquori, B.M.; Thorpe, D.E.; Fuchs, R.K. Designing Exercise to Improve Bone Health among Individuals withCerebral Palsy. Pediatr. Phys. Ther. 2021, 33, 50–56. [CrossRef]77. Rapson, R.; King, T.; Morris, C.; Jefferey, R.; Mellhuish, J.; Stephens, C.; Marsden, J. Effect of different durations of using a standingframe on the rate of hip migration in children with moderate to severe cerebral palsy: A feasibility study for a randomisedcontrolled trial. Physiotherapy 2022, 116, 42–49. [CrossRef]78. Wright-Ott, C. Mobility Matters-Imbedding Hands-Free Locomotion Experiences into the Preschool and Elementary Curriculafor Students with Severe Speech and Motor Impairment: The Bridge School Experience. Bridge School Curriculum. 2018.Available online: https://curriculum.bridgeschool.org/wp-content/uploads/sites/5/2018/06/mobility_matters.pdf (accessedon 27 January 2023).79. Goodwin, J.; Lecouturier, J.; Basu, A.; Colver, A.; Crombie, S.; Smith, J.; Howel, S.; McColl, E.; Parr, J.R.; Kolehmainen, N.; et al.Standing frames for children with cerebral palsy: A mixed-methods feasibility study. Health Technol. Assess. 2018, 22, 1–231.[CrossRef]80. Hughes, S.; Campbell, L. Children with cerebral palsy: Perspectives and experiences of using standing frames. Assoc. Paediatr.Chart. Physiother. J. 2014, 5, 30–37.81. Paleg, G.; Alitizer, W.; Malone, R.; Ballard, K.; Kreger, A. Inclination, hip abduction, orientation, and tone affect weight-bearing inpediatric standing devices. J. Pediatr. Rehabil. Med. 2021, 14, 433–441.82. Herman, D.; May, R.; Vogel, L.; Johnson, J.; Henderson, R.C. Quantifying weight-bearing by children with cerebral palsy while inpassive standers. Pediatr. Phys. Ther. 2007, 19, 283–287. [CrossRef]83. Kecskemethy, H.H.; Herman, D.; May, R.; Paul, K.; Bachrach, S.J.; Henderson, R.C. Quantifying weight bearing while in passivestanders and a comparison of standers. Dev. Med. Child. Neurol. 2008, 50, 520–523. [CrossRef]84. Broadbent, J.; Woollam, P.J.; Major, R.E.; Stallard, J. Technical note: A rear support walking frame for severely disabled childrenwith cerebral palsy: Initial development. Prosthet. Orthot. Int. 2000, 24, 233–240. [CrossRef]85. Paleg, G.; Huang, M.; Vasquez Gabela, S.C.; Sprigle, S.; Livingstone, R. Comparison of the Inertial Properties and Forces Requiredto Initiate Movement for Three Gait Trainers. Assist. Technol. 2016, 28, 137–143. [CrossRef]86. Cowan, R.; Davis, S. Physiotherapist opinions of barriers and facilitators that affect primary caregiver engagement with the use ofstanding frames for children with cerebral palsy: A qualitative study. Assoc. Paediatr. Chart. Physiother. J. 2018, 9, 27–37.87. Goodwin, J.; Colver, A.; Basu, A.; Crombie, S.; Howel, D.; Parr, J.R.; McColl, E.; Kolehmainen, N.; Roberts, A.; Lecouturier, J.; et al.Understanding frames: A UK survey of parents and professionals regarding the use of standing frames for children with cerebralpalsy. Child. Care Health Dev. 2018, 44, 195–202. [CrossRef]88. Goodwin, J.; Lecouturier, J.; Smith, J.; Crombie, S.; Basu, A.; Parr, J.R.; Howel, D.; McColl, E.; Roberts, A.; Miller, K.; et al.Understanding frames: A qualitative exploration of standing frame use for young people with cerebral palsy in educationalsettings. Child. Care Health Dev. 2019, 45, 433–439. [CrossRef]89. Bush, S.; Biggs, R. Assisted standing: Experiences of children with cerebral palsy and their physiotherapists. Assoc. Paediatr. Chart.Physiother. J. 2011, 2, 3–10.90. Daniels, N.; Gopskill, C.; Armstrong, J.; Pinnington, L.; Ward, C. An evaluation of standing frames designed for children:Preferences of users and therapists. Assoc. Paediatr. Chart. Physiother. J. 2005, 12–17.91. Taylor, K. Factors affecting prescription and implementation of standing-frame programs by school-based physical therapists forchildren with impaired mobility. Pediatr. Phys. Ther. 2009, 21, 282–288. [CrossRef]92. George, C.; Levin, W.; Ryan, J.M. The use and perception of support walkers for children with disabilities: A United Kingdomsurvey. BMC Pediatr. 2020, 20, 528. [CrossRef]93. Hornby, T.G.; Reisman, D.S.; Ward, I.G.; Scheets, P.L.; Miller, A.; Haddad, D.; Fox, E.J.; Fritz, N.E.; Hawkins, K.; Henderson, C.E.;et al. Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, andBrain Injury. J. Neurol. Phys. Therap. 2020, 44, 49–100. [CrossRef]Int. J. Environ. Res. Public Health 2024, 21, 669 18 of 1894. Valentín-Gudiol, M.; Mattern-Baxter, K.; Girabent-Farrés, M.; Bagur-Calafat, C.; Hadders-Algra, M.; Angulo-Barroso, R.M.Treadmill interventions in children under six years of age at risk of neuromotor delay. Cochrane Database Syst. Rev. 2017, CD009242.[CrossRef]95. Pool, D.; Valentine, J.; Taylor, N.F.; Bear, N.; Elliott, C. Locomotor and robotic assistive gait training for children with cerebralpalsy. Dev. Med. Child. Neurol. 2021, 63, 328–335. [CrossRef]96. Willoughby, K.L.; Dodd, K.J.; Shields, N.; Foley, S. Efficacy of partial body weight-supported treadmill training compared withoverground walking practice for children with cerebral palsy: A randomized controlled trial. Arch. Phys. Med. Rehabil. 2010, 91,333–339. [CrossRef]97. Rosen, L.; Plummer, T.; Sabet, A.; Lange, M.L.; Livingstone, R. RESNA position on the application of power mobility devices forpediatric users. Assist. Technol. 2023, 35, 14–22. [CrossRef]98. Huang, H.; Chen, C. The use of modified ride-on cars to maximize mobility and improve socialization-a group design. Res. Dev.Disabil. 2017, 61, 172–180. [CrossRef]99. Berry, E.; McLaurin, S.; Sparling, J. Parent/caregiver perspectives on the use of power wheelchairs. Pediatr. Phys. Ther. 1996, 8,146–150. [CrossRef]100. Livingstone, R.; Bone, J.; Field, D. Beginning Power Mobility: An exploration of factors associated with child use of early powermobility devices and parent device preference. J. Rehabil. Assist. Technol. Eng. 2020, 7, 1–12. [CrossRef]101. Feldner, H.A.; Logan, S.W.; Galloway, J.C. Why the time is right for a radical paradigm shift in early powered mobility: The roleof powered mobility technology devices, policy and stakeholders. Disabil. Rehabil. Assist. Technol. 2016, 11, 89–102. [CrossRef]102. Plummer, T.; Logan, S.W.; Morress, C. Explorer Mini: Infants’ Initial Experience with a Novel Pediatric Powered Mobility Device.Phys. Occup. Ther. Pediatr. 2020, 41, 192–208. [CrossRef]103. Butler, C. Effects of powered mobility on self-initiated behaviors of very young children with locomotor disability. Dev. Med.Child. Neurol. 1986, 28, 325–332. [CrossRef]104. Kuenzle, C.; Brunner, R. The effects of the Norsk Funktion-walking orthosis on the walking ability of children with cerebal palsyand severe gait impairment. J. Prosthet. Orthot. 2009, 21, 138–144. [CrossRef]105. Casey, J.; Rosenblad, A.; Rodby-Bousquet, E. Postural asymmetries, pain, and ability to change position of children with cerebralpalsy in sitting and supine: A cross-sectional study. Disabil. Rehabil. 2022, 44, 2363–2371. [CrossRef]106. Livingstone, R.W.; Chin, A.J.; Paleg, G.S. Power Mobility, Supported Standing and Stepping Device Use in the First Two Years ofLife: A Case Report of Twins Functioning at GMFCS V. Disabilities 2023, 3, 507–524. [CrossRef]107. Livingstone, R.W.; Paleg, G.S.; Field, D.A. Supported standing and stepping device use in young children with cerebral palsy,Gross Motor Function Classification System III, IV and V: A descriptive study. Assist. Technol. 2023, 1–11. [CrossRef]108. Logan, S.W.; Catena, M.A.; Sabet, A.; Hospodar, C.M.; Yohn, H.; Govindan, A.; Galloway, J.C. Standing Tall: Feasibility of aModified Ride-On Car That Encourages Standing. Pediatr. Phys. Ther. 2019, 31, E6–E13. [CrossRef]109. Huang, H.H.; Hsieh, Y.H.; Chang, C.H.; Tsai, W.Y.; Huang, C.K.; Chen, C.L. Ride-on car training using sitting and standingpostures for mobility and socialization in young children with motor delays: A randomized controlled trial. Disabil. Rehabil. 2023,45, 1453–1460. [CrossRef]110. Huang, H.H.; Chu, Y.-W.; Chan, Y.-T.; Chen, C.-L. A pilot randomised controlled trial of ride-on cars and postural combinationsof standing and sitting for mobility and social function in toddlers with motor delays. Disabil. Rehabil. Assist. Technol. 2024.[CrossRef]111. Macias-Merlo, L.; Bagur-Calafat, C.; Girabent-Farrés, M.; Stuberg, W.A. Effects of the standing program with hip abduction onhip acetabular development in children with spastic diplegia cerebral palsy. Disabil. Rehabil. 2016, 38, 1075–1081. [CrossRef]112. Macias-Merlo, L.; Bagur-Calafat, C.; Girabent-Farrés, M.; Stuberg, W.A. Standing programs to promote hip flexibility in childrenwith spastic diplegic cerebral palsy. Pediatr. Phys. Ther. 2015, 27, 243–249. [CrossRef]113. Barton, C.; Buckley, J.; Samia, P.; Williams, F.; Taylor, S.R.; Lindoewood, R. The efficacy of appropriate paper-based technology forKenyan children with cerebral palsy. Disabil. Rehabil. Assist. Technol. 2022, 17, 927–937. [CrossRef]114. Walle, E.A. Infant social development across the transition from crawling to walking. Front. Psychol. 2016, 7, 960. 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Supported Standing and Supported Stepping Devices for Children with Non-Ambulant Cerebral Palsy: An Interdependence and F-Words Focus
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