Knee Joint Loading During Supported Standing in Children and Adolescents with Severe Cerebral Palsy: Effects of Verticalization and Joint Position

BACKGROUND: Supported standing is widely used in children and adolescents with severe cerebral palsy (CP) as part of rehabilitation programs aimed at maintaining musculoskeletal health and enabling participation. Despite its frequent clinical use, quantitative biomechanical evidence describing knee joint loading under different positioning conditions remains limited, particularly in individuals classified as GMFCS IV-V. The primary objective of this study was to quantify knee joint loading during supported standing across predefined combinations of verticalization angle and hip/knee flexion. The secondary objective was to investigate interaction effects between these variables and to assess whether increasing hip/knee flexion is associated with a linear reduction in knee joint loading. METHODS: Twenty-six children and adolescents with CP (GMFCS IV-V; age 6-17 years) participated in the study. Measurements were performed using a standardized back-supported standing device. Knee joint loading was measured using integrated pressure sensors across six verticalization angles (0°, 30°, 45°, 60°, 75°, 90°) combined with four hip/knee flexion angles (0°, 15°, 30°, 45°). Forces were normalized to body weight (%BW). Statistical analysis was performed using repeated-measures analysis of variance. RESULTS: < 0.001). A non-linear pattern was observed across flexion angles. Interaction effects between verticalization and hip/knee flexion were observed. Knee joint loading did not decrease linearly with increasing flexion; instead, the lowest loading was observed at approximately 15° hip/knee flexion, whereas both full extension and 45° flexion resulted in higher loads. CONCLUSIONS: Verticalization angle represents a key factor influencing knee joint loading during supported standing in children and adolescents with severe CP. Knee joint loading increases with greater verticalization, while hip/knee position shows a non-linear influence. The absence of a linear reduction in loading with increasing flexion highlights the presence of interaction effects between positioning variables and supports individualized positioning strategies in supported standing programs.