Use of Overground Supported-Stepping Devices for Non-Ambulant Children, Adolescents, and Adults with Cerebral Palsy: A Scoping Review
- What BSF, activity, and participation outcomes from supported-stepping device use have been reported?;
- Are there any data available regarding: rates of use; costs; abandonment; adverse effects; contraindications; or equipment type in relation to age, desired outcomes or GMFCS levels?;
- Do experiences of stakeholders differ in regard to supported-stepping device use?;
- What are the barriers and facilitators of supported-stepping device use?
2.1. Inclusion Criteria
2.2. Exclusion Criteria
- Studies including mainly individuals classified as GMFCS I–III or those able to walk independently or use hand-held walkers;
- Studies using robotic devices, exoskeletons or mechanical stepping devices with external power sources, stationary systems (confined to parallel bars or treadmill), ceiling suspension systems or institutional-type gait trainers (e.g., LiteGait) too large to be used in a home or classroom environment;
- Where overground gait or ambulatory training was the comparison intervention, studies were included only if a supported-stepping device was the main comparison and not used in combination with partial body-weight supported treadmill training or other powered intervention(s).
2.3. Data Extraction and Appraisal
3.1. Syntheses and Guidelines
3.2. Primary Source Data
3.2.1. Sources of Evidence According to Supported-Stepping Device (SSD) Type
3.2.2. Use and Introduction of Supported-Stepping Devices (SSD) According to Age and GMFCS
3.2.3. Contraindications and Benefits of Supported-Stepping Device (SSD) Use
3.3. Expert Opinion
3.4. BSF, Activity and Participation Outcomes
3.5. Lived Experience of Supported-Stepping Device (SSD) Use
4.1. Outcomes and Use of Supported-Stepping Devices (SSD)
4.1.1. Use of Supported-Stepping Devices (SSD) for BSF, Activity, and Participation Outcomes
4.1.2. Use of Supported-Stepping Devices (SSD) According to GMFCS Level
4.1.3. Use of Supported-Stepping Devices (SSD) in Relation to Equipment Type and Orientation
4.1.4. Stakeholder Experiences of Supported-Stepping Device (SSD) Use
4.1.5. Barriers and Facilitators of Supported-Stepping Device (SSD) Use
4.2. Recommendations for Clinical Practice
4.3. Recommendations for Future Research
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
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Steiner, 2010 
|Review evidence for |
supported standing in
relation to occupational therapy theory
|Kuenzle , |
|Dynamic standers (SSDs) positively impact |
mobility and hand function. Prescription is supported by occupational therapy theory.
|Paleg, 2015 |
|Examine effect of SSDs on BSF, Activity or |
Participation outcomes for children up to 18 years
Van der Putten ,
|Youngest reported: 2–3 years; mean: 10 years.|
Recommended starting at 9–12 months.
Mainly positive evidence, but primarily
descriptive and insufficient to draw strong
conclusions. Trend to increased walking distance and number of steps. Significant increase in mobility level and improved bowel function. Association between increased weight-bearing and bone mineral density. Positive impact on affect, motivation, and participation.
|Paleg, 2016 |
|To review evidence and clinical |
selection of SSD
|6 interventions [17,18,61,64,75,93],|
3 devices [113,114,115],
1 device properties ,
3 expert opinions [80,92,96],
1 survey 
|Evidence supporting selection of SSDs and/or SSD features is descriptive. Research on all |
aspects of SSD development and prescription is needed.
|To review evidence supporting outcome measures that have been used, or may be useful for SSD outcomes||Barnes ,|
Van der Putten ,
|Functional and individualized measures are more useful than spatio-temporal measures for GMFCS IV/V. Outcome measures for this population and intervention require |
|Booth, 2018 |
|Effectiveness of functional gait training in improving gait in children with CP||Willoughby ,|
|Functional gait training is safe and more |
effective for improving walking speed than
standard physical therapy.
Only interventions with partial body weight support are suitable for GMFCS IV/V.
|Novak, 2020 |
|Summarize best available evidence for managing CP in 2019||Paleg, 2015 ||Low quality evidence supports use of SSDs to |
increase gross-motor function and ability to step for GMFCS IV/V. Weak + recommendation.
|Paleg, 2021 |
|Review use of postural management interventions to promote hip health in children and adults with |
|Paleg, 2015 ||No studies have examined impact of SSDs on hip health. Clinical recommendation: |
active weightbearing and movement in SSD to
promote position change and reduce sedentary behavior.
|Gannotti, 2021 |
Declared no COI
|Exercise interventions for bone health: guidelines for individuals with CP||N/A||Overground fast walking in SSD may provide moderate osteogenic exercise for GMFCS IV. Active assisted movement opportunities may benefit GMFCS V.|
|Jackman, 2022 |
Declared no COI
|Clinical guideline: |
interventions to improve physical function in
children with CP
|Novak, 2020 ,|
Booth, 2018 
|Overground more effective than partial body-weight supported treadmill training to|
increase walking distance for GMFCS IV/V. SSDs used for inclusion and well-being rather than functional mobility.
|de Campos, 2023 |
|Scoping review: early |
interventions for young children GMFCS IV/V
|SSDs positively impact functioning, fitness, fun, friends, family and future for children |
under 5 years who are non-ambulant.
|Source||Randomized controlled group design (RCT)|
|Willoughby et al., 2009 |
Declared no COI
11 GMFCS IV
3 GMFCS III
11.24 ± 4.17 years
7 GMFCS IV
5 GMFCS III
10.35 ± 3.14 years
|30 min 2 times per week for 9 weeks|
Controls: Overground walking with anterior support-arms SSD # (GMFCS IV) or posterior walker # (GMFCS III)
Partial body-weight supported treadmill training (PBWSTT)
|No statistically significant between-group differences in:|
endurance (10 Minute Walk Test); or speed (10 Meter Walk Test).
Trend to increased walking distance and endurance favoring overground training. Trend to decreased walking distance in PBWSTT group.
Conclusion: to improve overground walking, practice overground.
|Non-randomized group designs|
|Eisenberg et al., 2009 |
COI and funding not reported
11 GMFCS IV/V
6.1 ± 2.1 years
11 GMFCS IV/V
6.8 ± 1.7 years
|Use over 6 months: |
Hands-free orthotic SSD
2.1 ± 1.8 increased to 4.5 ± 2.3 h per week
2.1 ± 1.8 h per week
Increased PEDI mobility (p = 0.03).
Decreased constipation (p = 0.02).
Increased walking distance.
Participants and Controls:
Moderate association between increased BMD and increased weightbearing in stander or SSD.
|van der Putten et al., 2005  |
COI and funding not reported
32 GMFCS IV/V
Mean 8.8 years
12 GMFCS IV/V
Mean 10.6 years
12 months MOVE® program including use of anterior support-arms SSD with sling seat
12 months regular education and therapy program
|Both groups increased movement skill independence on TDMMT. |
MOVE®: 19.2 ± 13.5 to 22.8 ± 14.5.
Controls: 20.2 ± 16.3 to 22.3 ± 19.2.
Significant increase (p < 0.001) with moderate ES (0.69): MOVE® group.
4/12 controls improved.
20/32 MOVE® group improved.
|Pre-post single group designs|
|Kuenzle and Brunner, 2009 |
Declared no COI
Distributor involved in study conduct and planning
|45 GMFCS IV|
48 GMFCS V
Mean 7.6 years
|Hands-free orthotic SSD |
1 deceased, 4 returned SSD
0.8 h (0.2 to 2.5) day, 5 times per week (range 2–7)
|78 walked with little/no assistance; |
10 used for dynamic standing only.
Distance: 98.5 m ± 11.06 (2–463 m).
Significant increase in walking abilities (WeeFIM) p < 0.001.
Parents rated significantly increased mobility independence compared with no SSD (p < 0.001), but only hand function improved compared with previous device (p < 0.001).
Goals for SSD met or exceeded: 81% parents and 86% therapists.
Contraindications: hip/knee flexion contractures > 20 degrees; ankle dorsiflexion < 0 degrees.
|Smati et al., 2022 |
Declared no COI
|4 GMFCS III|
5 GMFCS IV
|12-week, 50 min, 3 times per week intensive power |
training during school PE
GMFCS IV used SSDs
GMFCS III used walkers
|Results for GMFCS IV only: |
HR/min 1.57 ± 0.72 to 0.95 ± 0.53.
10 MWT 15.62 ± 10.1 to 11.86 ± 5.65 s.
10 MFWT 10.32 ± 3.14 to 8.64 ± 3.42 s.
50 MST 67.4 ± 34.63 to 50.4 ± 17.78 s.
6-min walk endurance 162.75 ± 44.46–269.77 ± 88.05 m.
Greatest change: children 6, 7, 8 yrs. 10, 11 yr. old results relatively stable.
|Wright and Jutai, 1999 |
|5 GMFCS IV|
15 GMFCS V
7.9 ± 2.9 years
|Hands-free orthotic SSD for 12 months|
Initial use: 30 min daily
Mean use from 2–12 months: 322 min ± 190.5 per week (range 92.5–860)
|Significant increase (p = 0.006) in GMFM walk run jump (WRJ) score in SSD from 2–12 months: 6.1 ± 6.1. |
DMA significant increase (p = 0.01) from 2–12 months: 6.6 ± 10.7.
Significantly increased walking speed and distance (p < 0.05).
PEDI mobility score increased mean 10% points (p = 0.04) with SSD introduction, then remained stable.
PEDI social function increased 6% points ± 8.5 by 12 months.
6 children walked indoors and out;
6 within home and classroom;
7 used for standing and exercise.
|Wright and Jutai, |
|9 GMFCS III|
10 GMFCS IV
Mean age at 36-month
follow-up 10.7 ± 3.1 years
12 children > 12 years
|Hands-free orthotic SSD||13/20 still used as main SSD.|
6/7 who discontinued were >12 years and had outgrown the device.
For 12/13 still using this SSD: non-significant increases (<3% points) in GMFM stand or WRJ.
DMA: significant increase in steering ability between 12 and 36 months: 12 to 28.6 (p = 0.02).
Walking speed unchanged.
PEDI caregiver assistance scale: mean gains in self-care (4; p = 0.52) and social function (6; p = 0.04) scales from 24–36 months.
|Bradbury and Tierney, 2022 |
Declared no COI
|Parent of 1 GMFCS IV |
(Excluded 7 children and 5 parents at GMFCS II/III)
|1 GMFCS IV: ring style SSD|
PTs discussed varied SSDs
|Child safety, comfort, and happiness influence parent use of SSDs.|
PTs split between valuing child function and participation and promoting gait pattern.
Recommendation: prioritize participation and child/family goals.
|McKeever et al., 2013 |
|Parents of children|
10 GMFCS IV
9 GMFCS III
Mean 10.7 years ± 3.1 years
|Hands-free orthotic SSD|
Parents interviewed 36 months after provision.
13 children still using this specific SSD
|Theme 1. Bodily function, position, and comportment.|
Theme 2. Communication.
Theme 3. Participation and inclusion.
Theme 4. Freedom and independence.
Parents report child appeared more able. They valued SSD for enabling social inclusion in daily life as much as enhanced independent mobility.
|Rodriguez Costa |
et al., 2021 
Declared no COI
|2 parents, 2 educational professionals and 4 PTs interviewed regarding experiences using the low-cost hands-free SSD with four children at GMFCS IV #|
Mean age 8.75 ± 5.5 years at time of study
Children started using SSD at age 3–6 years
|Low-cost charity developed|
Hands-free SSD used for 2.5 ± 1 years
|Theme 1. Emotional welfare: |
happiness, emotional regulation, and self-esteem.
Theme 2. Physical well-being:
improved fitness, bowel function, balance and walking.
Theme 3. Social Enjoyment:
integration with others, increased hand-use, and independent exploration.
Conclusion: Using the SSD made the children happier, increased self-confidence and autonomy, and enhanced participation.
|Paananen, 2009 |
|GMFCS IV/V *|
7 aged 3–6 years
5 aged 7–15 years
|Hands-free orthotic SSD|
7 used 4–6 months
1 used 7–9 months
4 used > 12 months
Used 30 min to 2 h daily
|Parents satisfied (score 4) or very satisfied (score 5) (QUEST 2.0).|
Device satisfaction 4.6 ± 0.93.
Services satisfaction 4.02 ± 1.01.
Most important factors:
Effective: Satisfied (2/12) or very satisfied (10/12).
Ease of use: only 5/12 satisfied.
Comfort: Satisfied (3/12) or very satisfied (9/12).
Children were motivated to use.
7/12 used for both standing and walking. Used indoors and out.
Increased participation in family life and with other children at school. Physical and attention benefits.
Negatives: difficulty with transfers.
|Single-subject research: Multiple baseline design|
|Barnes et al., 2002 |
|Case 3: 3.5 years; |
GMFCS V *
Case 4: 9 years
GMFCS IV *
Cases 1 and 2:
Case 5: did not use SSD
|Anterior support-arms SSD with sling seat, as part of MOVE® intervention over 8–9 months: stepping data collected twice weekly|
Case 3: 15-week baseline; 37-week intervention
Case 4: 20-week baseline; 32-week intervention
Two years maintenance data
|Case 3: Initially unable to weight-bear unless fully supported in stander. |
Unable to step in SSD or with adult support during baseline or intervention. Able to walk 100 ft in SSD in maintenance phase.
Case 4: Progressed to walking 70 ft in SSD; 9 min 20 s after 30 trials; 4 min 54 s by trial 53. Child unavailable in maintenance phase.
|Lancioni, 2005a  |
|GMFCS IV/V *|
Profound intellectual disability
Case 1: 10.8 years
Case 2: 47.7 years
|Straddle style SSD with chest support, saddle, and foot divider. Modified with automatic step counter and microswitch technology to activate preferred stimuli on stepping. 5-min sessions, 3–4 times daily, 4–6 times per week||Steps counted in baseline (Case 1: 6; Case 2: 24 sessions) but preferred stimuli (e.g., music, lights, vibration) activated only during intervention. Significant increase (p < 0.01) in steps (Case 1: 24 to 103; Case 2: 70 to 194) and indices of happiness: (Case 1: 1 to 5; Case 2: 1 to 7) during intervention phases for both.|
|Single-subject research designs: ABAB|
|Lancioni et al., [69,70,71,72,73,74] |
|GMFCS IV/V *; 3 to 43 years; Mean 13.26 ± 10.26 years; Profound intellectual disability; 9/17 severe |
Case 1: 13 years; 1 month 
Cases 2, 3: 10 years; 8 years 
Cases 4–7: 6.7 years; 8.9 years; 19.2 years; 41.2 years 
Case 8: 3 years (AB only) 
Case 9: 12 years 
Cases 10–14: 5.6 years; 6.5 years; 7.2 years; 11.4 years; 10.1 (AB only) years 
Cases 15–17: 10.5 years; 12 years; 34 years 
|Ring walker SSD with saddle or sling seat|
Modified with automatic step counter and microswitch technology to activate preferred stimuli
4.7 ± 0.82 (2–5) minutes
7.6 ± 7.74 (4–28) times per day
Total sessions in each intervention phase:
133.6 ± 171.82 (33 to 873)
|Significant increases (p < 0.01) in stepping, pushing or leg-foot movements in SSD and indices of happiness during intervention phases, with change of slope towards baseline during withdrawal phase.|
Cases 4 and 5: stepping significant at p < 0.05.
|Case series and observational studies|
|Broadbent et al., 2000 |
|GMFCS IV *|
Case 1: 9 years
Case 2: 14.5 years
Case 3: 8 years
Case 4: 8 years
|Study-specific hands-free orthotic SSD|
1. 30 min 3 times per week
2. 2 h 4 times per week
3. 4 h 5 times per week
4. 40 min 2–4 times per week
|Independent walking increased (body weight support %).|
1. >400 m indoor/outdoor (37%).
2. 10–25 m indoors (81%).
3. >400 m indoor/outdoor (69%).
4. 100–400 m outdoors (63%).
|Camallonga, 2010 |
|10 children, aged 1–4 years.|
6 GMFCS IV
4 GMFCS V
Age 18–52 months;
children determined not to be candidates:
3 GMFCS IV, 3 GMFCS V;
Level of Sitting Scale (LSS):
LSS 2:1; LSS 3:3; LSS 8:1
3 weeks to 3 months, 3 weeks
|Hands-free orthotic SSD used in early intervention setting||Case 1: 29 months, GMFCS IV, LSS 4, dev. age 11 months.|
Case 2: 21 months, GMFCS IV, LSS 4 dev. age 7 months, 2 weeks.
Case 3: 38 months, GMFCS V, LSS 3, dev. age 6 months.
Case 4: 44 months, GMFCS IV, LSS 4, dev. age 18 months.
Protocol for successful candidates: LSS 2–4; GMFCS IV/V; developmental age 6 months.
3/4 stepping to explore classroom. 1/4 mainly standing. All increased motivation, self-expression.
|Gandarias Mendieta, 2012 |
|126 children < 18 years|
11 adults GMFCS IV/V
|Longitudinal follow-up: hands-free orthotic SSD||GMFCS III: this SSD type limits their autonomy and function. |
GMFCS IV: achieve most functional stepping, indoor and outdoor use.
GMFCS V: improved posture, head, and saliva control. Important for self-esteem. May use for dynamic standing and some can step.
|Gandarias Mendieta, 2023 |
Unpublished longitudinal clinical database, all new device users in Spain provided by author
16 January 2023
|40 GMFCS III/other conditions|
105 GMFCS IV
180 GMFCS V
Total GMFCS IV/V: 285
Includes population from previously reported 137 users  and 26 users from two independent studies [81,82]
Contact lost: 27 users
Deceased: 6 GMFCS V, 3 others
|Longitudinal follow-up of hands-free orthotic SSD use from 2010 to 2022|
Age: 12 months to 37 years
Average age of introduction: 3–6 years
Average use: 7 years
GMFCS IV: 96 <18 years;
GMFCS V: 142 <18 years;
|Current users as of December 2022: |
37 GMFCS IV and 74 GMFCS V.
Aged 2–34 years: mean 13 years.
Able to step: 32 GMFCS IV and 63 GMFCS V.
Using other SSD: 37 GMFCS IV and 4 GMFCS V.
No longer using due to poor health:
5 GMFCS IV and 42 GMFCS V.
Outgrown size: 33 GMFCS IV and
48 GMFCS V.
|Livingstone et al., 2023 |
|8 GMFCS III|
15 GMFCS IV
19 GMFCS V
47.74 months ± 14.71 months
|SSD use over 6 months|
III:6/8 IV:13/15 V:13/19
III: 8/8 IV:14/15 V:14/19
|SSD type according to GMFCS:|
III: 6 Convertible; 2 Support-arms.
IV: 9 Support-arms; 5 Hands-free.
V: 12 Hands-free; 2 Support-arms.
No significant change in SSD use over 6 months. Power mobility introduction did not reduce SSD use at any GMFCS level.
|Low, 2005 |
|39 severe multiple disabilities|
>50% GMFCS IV/V *
Mean 9.2 years
|Anterior support-arms SSD with sling seat as part of MOVE® program over 1 year||31/39 increased mobility level 1/39 |
Increased independence in sitting, standing, and walking for all ages.
Increased alertness and ease-of-care.
|Low et al., 2011 |
|9 GMFCS IV|
1 GMFCS V
7.5 ± 3.3 years
|Comparison of *anterior support-arms SSD and *posterior hands-free SSD after 1 week trial in each||No significant group differences in gait speed/quality. Both SSDs improved upright mobility.|
For 6/10 new to SSDs, walking speed/gait quality better in hands-free SSD. 6 families preferred anterior. SSD: ease of transfers and use.
|Martin Gomez et al., 2012 |
English translation Manufacturer web publication
|7 GMFCS IV|
Mean 10.2 years
|Hands-free orthotic SSD Mean use: 8.5 h per |
week for 25.5 months
|Typical user is GMFCS V.|
20/26 parents were very satisfied.
QUEST 2.1 mean score 4.29 (2.4–6.3).
|Martin Gomez et al., 2021 |
|19/26 GMFCS IV/V |
followed longitudinally since 2012 analysis
|Hands-free orthotic SSD|
Mean use 5.2 years
Range 2–9 years
|1/19 still using device. |
Reasons for discontinuation:
increased deformity (13); size (3); improved abilities (2); time (1).
QUEST 2.1 mean 3.12 (1.2–5.3).
|Paleg, 1997 |
|19 GMFCS IV/V #|
Unable to sit, stand or walk
Mean 6 years (2–14)
|Anterior support-arms SSD as part of one-week intensive in-patient 20-h program based on MOVE®||18/19 children able to reciprocally step more than 19 feet in SSD.|
11/19 maintain head control 30 s in upright supported sitting.
8/19 maintain hip and knee extension 30 s.
|Sharma and Bajracharya., 2022 |
Declared no COI
|5 GMFCS II-IV|
Results here reported for:
3 GMFCS IV #
Case 1: 8 years
Case 2: 7 years
Case 3: 6 years
|Examined feasibility and parent satisfaction with a low-cost hands-free SSD: modified standard 4-wheel reverse walker by adding circumferential trunk support and sling seat||# Parents quite/very satisfied: QUEST 2.0 total 4.85 ± 0.25.|
Most important items: dimensions: 4.85 ± 0.25; ease of use: 5/5; effectiveness: 4 ± 1.
All able to take a few steps hands-free. Case 1 able to play ball games and drink independently in SSD.
Modification: feasible option for lower-resourced settings.
|Wright-Ott, 2018 |
|29 children 3–10 years|
1 GMFCS III
5 GMFCS IV
20 GMFCS V
3 unknown genetic
|Hands-free SSDs |
Preschool aged children; used 30–60 min daily
Elementary aged children; used 15 min daily in recess and 30 min 3 times per week in gym and math/science
|Teacher, family, and therapist observations: increased interaction with peers, visual attention, self-initiated behavior, problem solving, engagement, upper extremity use, physical motor control and communication.|
|George et al., 2020 |
Declared no COI
|UK SSD prescribers (105 PTs, 1 OT, 1 PT aide) and 18 non-prescribers (worked with children using SSDs: PT, OT, education staff)||Prescribers/non-prescribers familiar with a wide range of SSD types. Most commonly prescribed SSDs were: anterior support-arm with sling seat (95/107); anterior-posterior with saddle seat (42/107) and posterior hands-free (38/107). |
as much as able (53/107); <30 min (6/107); 30–60 min (34/107); >1 h (14/107)
<10 min (1/17); 10–30 min (6/17); 30–60 min (6/17); >1 h (4/17)
2–5 years (1–10+)
|Mean age of introduction 3.6 ± 1.6 years. Youngest age 2.4 ± 1.4 years, dependent on condition, cognition, motivation and motor ability. |
Conflict between early SSD use as bridge to independent walking or when other options unsuccessful.
Contraindications: lack of head control, pain, behavioral problems.
Most common reason for discontinuing use: functional deterioration.
Challenges: lack of staff, space, or child prefers other mobility method.
Top benefits: prescribers: physical activity, enjoyment, participation.
Non-prescribers: independence, physical activity, enjoyment. <20% children progress to using hand-held walkers.
|Low et al., 2011 |
Declared no COI
|513 US pediatric PTs who used SSDs||Commonly prescribed SSDs: anterior support-arms with sling seat (402/513); |
suspension posterior walker (360/513);
anterior support-arms with solid seat (329/513);
posterior hands-free (46/513)
<5 h/week (42%); 5–10 h/week (63%); >10 h/week (74%)
Duration of use:
<6 months (36%); 6 months–1 year (20%); 1–2 years (12%); >2 years (15%)
|Factors influencing success: |
GMFCS level, motivation to walk, and cognition.
Commonly recommended to increase exercise.
Used in both posterior (65%) and anterior (53%) configurations. PTs consider hip stability, respiratory, and cardiovascular function and BMD when prescribing SSDs.
Use of SSDs encouraged through participation with peers and school activities and within ADL activities.
30–50% children progress to walking with hand-held walkers.
|Peredo et al., 2010 |
Declared no COI
|52 children with CP (GMFCS not reported) as part of survey of medical device use in 108 children with disabilities||Unspecified SSD||10/52 CP used SSDs, 11/52 used walkers. One other child/108 with a genetic condition used an SSD. |
4/11 with SSD never used them, 2 used weekly, and 5 used daily.
|Roquet et al., 2018 |
Declared no COI
|234 GMFCS IV/V|
65 aged 2 to 17 years
170 aged 18 to >40 years
|Examine change in health-care use for individuals with CP in one region in northern France by age and GMFCS||Use of gait aids (unspecified) is stable but limited. 14–19% across all age groups for GMFCS IV/V. |
In comparison 68% ≤17 years use standing frames with decline to 16% at 18–24 years and 7% ≥25 years.
|Altizer and Paleg, 2020  |
|Hands-free SSD used daily from 12 months||SSD used to walk with support for exercise. Helps maintain fitness and participation with friends at the playground, store, and at school. Power mobility for longer distances.|
|Benson, 2020 |
|Unspecified SSD used daily in school||Used for free movement within the classroom and for short distances in school. Required power mobility for independence over longer distances.|
|Carnevale, 2015 |
|A. Anterior support-arms SSD |
B. Posterior hands-free SSD for 12 months
C. Anterior SSD with hand holds
|Anterior support-arms SSD: bore all weight on arms and dragged feet. |
Posterior hands-free SSD with full trunk support introduced: Over 12 months, learned to walk in upright position.
Anterior orientation re-introduced: able to use hands for steering rather than for support.
|Farrell et al., 2010 |
Declared no COI
|GMFCS IV *|
|Anterior support-arms SSD with sling seat|
30 min, 3–5 times per week:
4 weeks in-patient program
|Able to walk 150 feet with steering assistance. Increased weightbearing, weight shift and decreased hip flexion during stance. |
Increased GMFM (from 29.62 to 38.45) and PAM scores. Improved standing transfers and bed mobility.
|George, 2018 |
|GMFCS IV #|
cases 2 and 3:
not using SSD
|# Anterior support-arms SSD with solid seat|
Stander with side-to-side rocking base
10 min 3–5 times per week for 6 weeks
|TDMMT overall, standing, and walking scores improved from level 3 (dependent) to level 2 (walks 10 m with assistance). |
GAS-Light: consistently initiates and steps continuously over 10 m.
Increased reciprocal stepping.
|Gordon, 2023 |
online video cases
|Case 1: GMFCS IV|
Case 2: GMFCS V
Daily use from 9 months
|Case 1: Participation in family routines, improved hand use and play with siblings.|
Case 2: Limited active stepping and propulsion with assistance. Increased motivation and participation in gym games with other children in preschool.
|Jones, 2020 |
|Hands-free SSD||Able to take steps and walk short distances (up to 25 feet) inside the home. Power wheelchair prescribed to keep up with peers outdoors.|
|Kannegießer-Leitner (undated) |
Manufacturer web publication
|Case 1: GMFCS IV/V *|
Case 2: GMFCS IV *
Case 3: GMFCS V *
|Hands-free orthotic SSD||Case 1: Improved posture, able to step independently. Increased participation with family.|
Case 2: Motivated to walk 2–4 km daily. Increased sense of autonomy.
Case 3: Enjoys going for a walk outside after school 1.5–2 km daily.
|Low, 2004 |
|GMFCS IV *|
|Anterior support-arms SSD compared with previously used posterior hands-free SSD||Improved gait quality in anterior SSD. Easier transfers and increased |
mobility at home and school.
|Paleg, 1997 |
GMFCS IV #
|Anterior support-arms SSD with sling seat|
4 years MOVE® program
|Able to run in SSD, pull to stand, get up from floor with minimal assistance and sit independently.|
|Paleg, 1997 |
|Case 1: dystonic quadriplegia GMFCS IV #|
Case 2: spastic quadriplegia
GMFCS IV #
|Anterior support-arms SSD with sling seat |
MOVE® program for 1 year
Anterior support-arms SSD with sling seat
|Able to walk all over school in SSD. He is happy, has friends, is communicating and able to feed himself.|
Able to take a few independent steps at age 17. Improved speech, bowel function, and self-esteem.
|Paleg, 1998 |
GMFCS IV #
|SSD, stander, and classroom seat used 20 min each daily for one year||Able to sit to stand with hands held, maintains for 15 s, takes reciprocal steps for 10 feet in SSD.|
|Paleg, 2007 |
GMFCS IV #
|Anterior support-arms SSD with solid seat used daily and PBWSTT 8 min 3 times per week from 12 months||27 months: able to step forward and backwards in SSD with solid seat.|
36 months: able to sit to stand and step taking partial body-weight in dynamic anterior sling seat SSD.
|Pope et al., 2022 |
|# Anterior support-arms SSD with solid seat||Early upright positioning with stander. SSD for mobility and participation with siblings outdoors.|
|Schneiders (undated)  |
Manufacturer web publication
|Several GMFCS V|
Starting at 18 months
|Hands-free orthotic SSD||Alternate between active and static standing. Increased field of view and upright posture changes self-perception and perception of others.|
Increased self-determination: able to actively approach people or toys or communicate ‘no’ by moving away. Opportunity for motor and socio-emotional development.
|Schwerin, 2005  |
|3 GMFCS IV|
|Hands-free orthotic SSD for 6 months following botulinum toxin injections to decrease scissoring||Increased trunk control and weightbearing. Improved communication, attention, exploration and independent activity. |
Caregiver support and space needed for implementation.
|Thompson, 2005 |
|Case 1: |
GMFCS IV *
GMFCS IV *
6 ½ years
|Case 1. Anterior support-arms SSD with sling seat as part of MOVE® program for 2.5 years|
Case 2. Anterior support-arms SSD with sling seat as part of MOVE® program for 4 years
|Case 1: Walks 500 ft in SSD. Increased independence on TDMMT. Increased peer participation.|
Case 2: Increased independence on TDMMT. Walks length of gym in SSD and practices sit to stand. Stands with two-hand support. Uses power wheelchair with supervision.
|Whinnery et al., 2002 |
|GMFCS IV *|
|Anterior support-arms SSD with sling seat daily 6 months MOVE® program||Average daily steps increased from 0 to 125.|
|Citation||Source||Topic||Comments or Recommendations for |
GMFCS IV or V
|Bolton and Donohoe, 2020 ||Book chapter||Use of ambulatory assistive devices for children with CP||Can begin trial at 2 years with GMFCS IV/V|
Not useful for those with persistent flexor
|Covert, 2019 ||Periodical||Promote pediatric participation with standers, SSDs and wheeled mobility||SSDs can promote physical activity for GMFCS IV and possibly GMFCS V.|
When prescribing an SSD to promote participation and self-initiated mobility in the community,
consider folding and ease of transportation.
|Gandarias Mendieta, 2008 ||Manufacturer |
website translation of original Spanish language article
|Use and benefits of |
hands-free orthotic SSD
|For standing: promotes even weightbearing and slight movement in standing. Peer-level positioning increases participation with other children.|
For stepping: Promotes reciprocal gait, well-aligned posture, is stable and safe, increases child inclusion, participation and self-esteem.
Difficult to turn: not suitable for children able to walk with posterior walker or with hands held. Contractures at hips or knees > 20 degrees.
|Manufacturer web publication||Benefits of |
|Increases autonomy and independence for children requiring manual assistance to step. Reciprocating orthosis increases walking distance and reduces caregiver burden. Transfers may be modified for larger children by attaching trunk first, then knees and feet last. Beneficial for hip development. Others perceive child as more able.|
|Marquez, 2019 ||Periodical||Promoting function and independence in CP population||SSDs provide more support than walkers and can be used in anterior or posterior orientation. |
Maximize participation and independence rather than perfecting posture and gait mechanics.
|Thunberg et al., 2021 |
|Book chapter||Environmental modifications: for children with developmental motor disorders||Introduce SSDs around 12 months.|
SSDs promote upright positioning, active stepping and fitness, play, exploration and interaction.
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© 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Livingstone, R.W.; Paleg, G.S. Use of Overground Supported-Stepping Devices for Non-Ambulant Children, Adolescents, and Adults with Cerebral Palsy: A Scoping Review. Disabilities 2023, 3, 165-195. https://doi.org/10.3390/disabilities3020012
Livingstone RW, Paleg GS. Use of Overground Supported-Stepping Devices for Non-Ambulant Children, Adolescents, and Adults with Cerebral Palsy: A Scoping Review. Disabilities. 2023; 3(2):165-195. https://doi.org/10.3390/disabilities3020012Chicago/Turabian Style
Livingstone, Roslyn W., and Ginny S. Paleg. 2023. "Use of Overground Supported-Stepping Devices for Non-Ambulant Children, Adolescents, and Adults with Cerebral Palsy: A Scoping Review" Disabilities 3, no. 2: 165-195. https://doi.org/10.3390/disabilities3020012