Foot Weight-Bearing in Supported Standing: Influence of Verticalization Angles and Hip/Knee Flexion in Children and Adolescents with Cerebral Palsy (GMFCS IV-V)

TL;DR

This study shows that children with severe cerebral palsy can achieve meaningful foot weight-bearing during standing, even with hip and knee flexion, by adjusting verticalization angles.

Contribution

The study provides empirical evidence that hip/knee flexion does not prevent effective plantar loading, and identifies verticalization angle as the key factor.

Findings

Plantar loading increases progressively with higher verticalization angles, reaching >70% body weight at 60° in most flexion conditions.

Maximum plantar loading (96.4% BW) was observed at 90° verticalization with 30° hip/knee flexion.

Hip/knee flexion does not linearly reduce plantar loading; substantial loading remains even at 45° flexion.

Abstract

What are the main findings?
Plantar loading increases progressively with higher verticalization angles, and clinically relevant loading (>70% body weight) is already achieved at approximately 60° verticalization in most hip/knee flexion conditions.Hip and knee flexion does not result in a linear reduction in plantar loading; substantial loading is maintained even at 45° flexion, with the highest loading observed at 90° verticalization and 30° hip/knee flexion.

Plantar loading increases progressively with higher verticalization angles, and clinically relevant loading (>70% body weight) is already achieved at approximately 60° verticalization in most hip/knee flexion conditions.

Hip and knee flexion does not result in a linear reduction in plantar loading; substantial loading is maintained even at 45° flexion, with the highest loading observed at 90° verticalization and 30° hip/knee flexion.

What is the implication of the main finding?
Effective and clinically meaningful plantar loading can be achieved in children and adolescents with severe cerebral palsy even in the presence of relevant hip and knee flexion, thereby enabling effective foot weight-bearing and supporting flexible and individualized standing positioning strategies.When prescribing and adjusting supported standing systems, the verticalization angle should be prioritized as the primary determinant of plantar loading, while joint flexion should not be considered a contraindication for effective foot weight-bearing.

Effective and clinically meaningful plantar loading can be achieved in children and adolescents with severe cerebral palsy even in the presence of relevant hip and knee flexion, thereby enabling effective foot weight-bearing and supporting flexible and individualized standing positioning strategies.

When prescribing and adjusting supported standing systems, the verticalization angle should be prioritized as the primary determinant of plantar loading, while joint flexion should not be considered a contraindication for effective foot weight-bearing.

Background: Supported standing is commonly prescribed for children and adolescents with cerebral palsy (CP) to support musculoskeletal health and participation. However, objective data on plantar loading under different positioning conditions are limited, particularly in individuals with severe motor impairment (GMFCS IV–V). This study quantified plantar loading as an operational measure of foot weight-bearing during supported standing across combinations of verticalization angle and hip/knee flexion. Methods: Twenty-six children and adolescents with CP (GMFCS IV–V; 6–17 years) were assessed using a standardized back-supported standing system. Plantar loading was measured with two calibrated force plates at six verticalization angles (0°, 30°, 45°, 60°, 75°, 90°) combined with four hip/knee flexion angles (0°, 15°, 30°, 45°). Loading was expressed as a percentage of body weight (% BW). Effects were analyzed using repeated-measures analysis of variance. Results: Plantar loading increased progressively with increasing verticalization angles across all hip/knee flexion conditions. Clinically relevant loading levels (>70% BW) were achieved at a verticalization angle of 60° in most flexion conditions. Maximum plantar loading was observed at 90° verticalization combined with 30° hip/knee flexion (96.4% BW). At 90° verticalization, plantar loading remained substantial even with 45° hip/knee flexion (81.4% BW). Increasing hip/knee flexion did not result in a linear reduction in plantar loading; a significant decrease was observed only at 45° flexion. Conclusions: Verticalization angle is the primary determinant of plantar loading during supported standing in children and adolescents with severe CP. Clinically meaningful plantar loading—and thus effective foot weight-bearing—can be achieved at moderate verticalization angles despite hip and knee flexion, supporting flexible positioning strategies.

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