R E S E A R C H R E P O R T

The Influence of Position on Leg

Movements and Kicks in Older
Infants With Spina Bifida
David Chapman, PT, PhD
Doctor of Physical Therapy Program, St. Catherine University Minneapolis, Minnesota.

Purpose: The purpose of this study was to describe the frequency with which infants with lumbar or sacral
spina bifida (SB) move their legs or kick when they are 7 months and older while in the supine position,
seated in a conventional infant seat (CS), and seated in a specially designed infant seat (SDIS). Methods:
The spontaneous leg movements of 9 infants with lumbar or sacral SB were videotaped once per month for
4 months in each position. Results: Infants generated significantly more leg movements when seated in the
SDIS than in the CS and significantly more kicks in the SDIS than in the other 2 positions. Conclusions: The
movement context influences the ability of older infants with SB to move their legs and to kick. (Pediatr Phys
Ther 2016;28:380–385) Key words: infant motor development, spina bifida, spontaneous leg movements

Our understanding of how infants with spina bifida designed infant seat (SDIS).4,5 These same infants moved
(SB) learn to generate coordinated leg movements dur- their legs significantly more often and demonstrated sig-
ing their first year of life is limited to a small number of nificantly more kicks when they were seated in the SDIS
studies that have examined their spontaneous leg move- than in the supine position or seated in a CS.4,5 They
ments in different positions at different ages.1-5 For exam- also explored greater amounts of their lower extremity
ple, neonates with SB when in the supine position decrease range of motion when they were in the supine position
the frequency of leg movements during the first week of than they were seated in either of the infant seats.4,5 They
life.1 At 1, 3, 6, and 9 months of age, infants with SB gen- did not, however, increase or decrease how often they
erate fewer leg movements2,3 when they are in the supine moved their legs or kicked between 4 and 7 months of
position that are shorter in duration,2 less complex, and age.4,5
less organized3 than infants who are typically developing These studies show that young infants with lumbar
(TD). Between 4 and 7 months of age, infants with lumbar or sacral SB up to 7 months of age vary the frequency
or sacral SB move their legs less often and spontaneously of leg movements and kicks depending on position. For
generate fewer kicks than the age-matched infants who are example, at 5.5 months of age, infants produced an aver-
TD when both groups are in the supine position, seated in age of 33 leg movements and 3 kicks per minute seated
a conventional infant seat (CS), and seated in a specially in a CS that provided maximal support to their heads,
backs, hips, and legs.4,5 Alternatively, when they were
placed in a SDIS that provided much less physical sup-
0898-5669/110/2804-0380 port to their legs, they generated 90 leg movements and
Pediatric Physical Therapy
Copyright C 2016 Wolters Kluwer Health, Inc. and Academy of 12 kicks per minute.4,5 The current literature, however,
Pediatric Physical Therapy of the American Physical Therapy does not describe the frequency of leg movements and
Association kicks for infants with lumbar or sacral SB who are older
than 7 months in different positions. The purpose of this
Correspondence: David Chapman, PT, PhD, St. Catherine University
601 25th Ave S, Minneapolis, MN 55454 ([email protected]) study was to describe the frequency of leg movements
Grant Support: This study was supported, in part, by an EARDA Pilot and kicks of infants with lumbar or sacral SB who were
Research Study grant awarded to the author via St. Catherine University 7 months and older when in the supine position, in a CS,
from the Eunice Kennedy Shriver National Institute of Child Health and and in a SDIS. I anticipated that the infants would gener-
Human Development (NICHD).
The author declares no conflicts of interest.
ate more leg movements and kicks when they were posi-
tioned in a SDIS than they were in the supine position or in
DOI: 10.1097/PEP.0000000000000299
a CS.4,5

380 Chapman Pediatric Physical Therapy

Copyright © 2016 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
METHODS participation incentive of $10.00 was paid to each baby per
Institutional Review Board approval was obtained visit. Table 1 includes participants’ characteristics.
for this prospective descriptive study prior to participant Movement Data Collection
recruitment. Participants were recruited through the
myelomeningocele clinic at a large metropolitan hospital Infants’ leg movements were videotaped at 30 Hz
located in the upper Midwest. Their parents were informed (Sony HD Handycam). Two-dimensional data were col-
of the purposes of this study and provided written informed lected because the purpose of the study was to describe fre-
consent before data were collected. quency of movement, not to obtain kinetic data for which
3-dimensional data would be more appropriate. The cam-
era was mounted on a tripod 82 cm above the floor and
Description of Participants positioned up to a maximum of 2 m from and perpendic-
Participants were 9 infants with lumbar or sacral SB. ular to the infants’ feet. This resulted in the optical axis of
They were recruited at 6.75 months or older, had a lumbar the camera lens at an angle of approximately 22◦ with the
or sacral spinal lesion due to SB, and were not walking. horizontal line of the floor when the camera was 2 m from
Participants were born full-term except 1 baby was born the infants’ feet.
1 week prior to full-term. Infant age at entry was 6.75 to Data were collected monthly for 4 consecutive months
11.5 months, with an average age of 8.75 ± 1.55 months. at home. Before videotaping, the parent removed the baby’s
Stationary motor ages, as assessed by the Peabody Develop- clothes to the infant’s diaper and tee-shirt. A reflective
mental Motor Scale–Second Edition (PDMS-2), was 1 to 10 hemispherical marker approximately 2.0 cm in diameter
months, with a mean of 6.22 ± 3.15 months. Locomotion was placed on the sole of each foot at the head of the first
motor ages were from 3 to 8 months, with a mean of 5.11 metatarsal. These were attached with paper tape to avoid
months ± 1.83 months.6 Eight of the infants were born allergic reactions.
via planned cesarean delivery. One infant had a spinal le- Leg movements were videotaped for 2-minute trials
sion repaired at 6 months of age, whereas the other infants each in the supine position on a towel on the floor, seated
had their spinal lesions repaired during the first day of life. in a CS (Figure 1), and seated in the SDIS (Figure 2).
Five infants had ventricular-peritoneal shunts and 1 infant The order of position (supine, CS, SDIS) replicated
had a ventricular-atrial shunt placed before beginning this previous research, which demonstrated that moving from
study. None of the infants took medications that would the supine position to a more upright posture enabled
have impacted their ability to move their legs or kick. A the infants to be alert and active during each trial.4,5

TABLE 1
Participant Characteristics

Stationary/
Locomotion
Age at Entry Motor Ages at
Into the Entry Into the Level of Surgical Orthopedic
Participant Gender Study, mo Study,a mo Race Lesionb Procedures Impairments

1 Female 8.5 1/3 White L2-L4 VA shunt Bilateral clubfoot

G-tube Absent patellae
Tracheotomy Bilateral hip dysplasia
2 Male 7.0 10/6 White L5-S1 VP shunt ...
3 Male 6.75 4/3 White L1 ... Scoliosis
Clubfoot
Plagiocephaly
Torticollis
Duplicate femur
4 Male 11.25 4/5 Hispanic L4 VP shunt Left hip dysplasia
Bilateral clubfoot
5 Female 11.5 10/8 White S2-S4 Tethered cord release ...
6 Male 8.0 8/7 White S1-S2 ... ...
7 Female 8.5 5/3 White L4-S1 VP shunt Bilateral hip dysplasia
Tracheotomy
8 Female 8.75 5/5 White L4-S1 Bilateral Achilles tendon Bilateral clubfoot
releases
Bilateral hip dysplasia
9 Female 8.75 9/6 White L5 VP shunt Bilateral clubfoot
Bilateral Achilles tendon
releases

Abbreviations: L, lumbar spine; S, sacral spine.

a Stationary motor age/locomotion motor age in months as assessed by the Peabody Developmental Motor Scales, Second Edition (PDMS-2).
b Number indicates the vertebrae within that spinal segment.

Pediatric Physical Therapy Influence of Position on Leg Movements of Infants With Spina Bifida 381
Copyright © 2016 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
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 the leg medially, the first movement ended and the second
began at the point of change in direction.
To determine the total number of kicks generated
by each infant in each position, 6 types of kicks were
identified through coding the videotaped data of each
baby’s full set of leg movements.4,5,7 These included
single, parallel, and alternating leg kicks during which
the infant flexed and extended his or her leg(s) at the
hip and knee joint(s) and single, parallel, and alternating
knee kicks during which he or she flexed and extended
his or her leg at the knee joint(s) (Table 2). Four doctor
of physical therapy students in their third year of their
Fig. 1. Conventional infant seat. The seat provides maximal sup- professional program assisted with coding. Students were
port to the infant’s head, neck, trunk, and legs. trained by the author to identify leg movements and each
type of kick. They coded a 2-minute trial to document
During testing, the parent(s) or author was seated near their ability to accurately identify leg movements and
the infant’s side and interacted with the infant visually and kicks. They achieved a percent agreement with the author
socially. Each infant received a brief rest period between of 80% or more before completing the coding.
conditions.
Data Analysis
The difference between the CS and the SDIS is that
the SDIS is designed to provide firm support to the infant’s The data were analyzed using a 3 (Position) × 4 (Test
head and trunk while allowing unrestricted leg movements Session) multivariate analysis of variance (MANOVA),
at the hips and knees. An elastic cloth positioned around with repeated measures for position and test session. The
the infant’s chest and fastened with Velcro behind the back dependent variables were the average number of leg move-
support stabilized the trunk. ments and kicks generated per minute. Significant main
After videotaping during the first visit, the PDMS-2 effects, for example, position, were followed by univariate
was administered to obtain stationary and locomotion mo- tests, that is, leg movements or kicks, and pairwise com-
tor ages.6 These data provided descriptive information on parisons for either position or test session as appropriate.
control of the body within the center of gravity, for exam- All statistical analyses were completed with SPSS software
ple, when sitting or moving, or crawling.6 (version 22), with the α level set at P = .05.

Data Reduction RESULTS

Video data were behavior coded frame by frame to The average number of leg movements and kicks gen-
determine the onset and termination of leg movements for erated by this group of infants with SB in each position
each leg. These were defined as occurring when movement per minute are presented in Figure 3. The 3 (Position) × 4
of the marker stopped or started or when a change in (Test Session) MANOVA, with repeated measures for po-
direction occurred.4,5,7 For example, if a baby moved his sition and test session revealed a significant position effect
or her leg laterally and then reversed direction and moved (Wilks λ = 0.479, F4,30 = 3.342, P = .022) for leg move-
ments and kicks (partial η2 = 0.308, and observed power
= 0.780). Univariate tests confirmed the significant main

TABLE 2
Types of Kicks

Kick Type Description of Kick

Single knee kick One leg is flexing and extending at the

knee while the other leg is not moving or
doing something else.
Single leg kick Hip and knee of one leg is flexing and
extending while the other leg is not
moving or doing something else.
Alternating knee kick The knees are flexing and extending in
alternation.
Fig. 2. Specially designed infant seat. The seat positions the Alternating leg kick The legs are flexing and extending at the
infant’s trunk at an angle of 45◦ from the horizontal and pro- hips and knees in alternation.
vides firm support to the trunk and the head. The base of the Parallel knee kick Both knees are flexing and extending
seat is 33 cm high, which prevents the infant’s feet from touch- simultaneously.
ing the support surface. An elastic cloth positioned around the Parallel leg kick Both legs are flexing and extending at the
infant’s chest and fastened with Velcro behind the back support hips and knees simultaneously.
is used to stabilize the infant’s trunk.

382 Chapman Pediatric Physical Therapy

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Fig. 3. Average number of total leg movements and kicks pro- Fig. 5. Frequency of types of kicks generated in each position.
duced in each position. The average number of total leg move- The average number of each type of kick generated per minute
ments and kicks produced per minute plus 1 SD in each position. in each position. SKKs indicates single knee kicks; SLKs, single leg
kicks; AKKs, alternating knee kicks; ALKS, alternating leg kicks;
PKKs, parallel knee kicks; and PLKs, parallel leg kicks.
effect of position for the overall frequency of leg move-
ments (F2,16 = 5.285, P = .017, partial η2 = 0.398, and how often this group of infants generated each type of kick
observed power = 0.757) and kicks (F2,16 = 7.41, P = in each position.
.005, partial η2 = 0.481, and observed power = 0.888). There was not a significant test session effect on the
Infants generated significantly more leg movements frequency of leg movements or kicks produced by this
when they were seated in the SDIS than when they were group of infants in SB (Wilks λ = 0.846, F6,46 = 0.670,
seated in the CS (P = .009). The frequency of leg move- P = .674). Figure 6 illustrates the average number of leg
ments generated when they were in the supine position movements and kicks produced per minute during each
versus when they were seated in the SDIS was not signif- test session.
icant (P = .100). There were no significant differences in
the number of leg movements generated when the infants DISCUSSION
were in the supine position compared with when they were
The purpose of this study was to describe how often
seated in the CS (P = .318).
infants with lumbar or sacral SB who were 7 months
Figure 4 illustrates the variability by subject in the
and older moved their legs and kicked when they were
number of leg movements produced in each position. The
in the supine position, seated in a CS, and seated in a
range of leg movements produced by the infants was small-
SDIS. As expected, this group of infants with lumbar or
est in the CS, largest in the SDIS, and the most active baby
sacral SB moved their legs and kicked significantly more
in one position was not necessarily the most active in an-
often when they were seated in the SDIS than when they
other, for example, infants 1, 2, and 8.
were placed in the CS and generated significantly more
The infants generated significantly more kicks per
kicks when they were seated in the SDIS than when they
minute when they were seated in the SDIS than they were
were in the supine position. They did not, however, move
seated in either of the other 2 positions, with single knee
their legs more often, on average, when they were in the
kicks being the most common type of kick observed in
SDIS than when they were in the supine position. This
each position. Infants generated more kicks per minute,
statistical outcome reflects the wide chronological age
on average, when they were seated in the SDIS than when
range of the infants who participated in this study as well
they were positioned in the CS (P = .016) and when they
as the range of their motor development as measured by
were in the supine position (P = .033). There was not
the PDMS-2.6 It is possible that a group of infants with SB
a significant difference in the number of kicks they pro-
who showed less variation in their chronological age and
duced when in the supine position compared with when
motor development may also demonstrate less variability
they were seated in the CS (P = .587). Figure 5 illustrates
in how often they move their legs. It is also possible that

Fig. 4. Average number of leg movements produced in by each Fig. 6. Average number of leg movements and kicks produced
infant in each position. The average number of total leg move- per test session. The average number of leg movements and kicks
ments generated per minute by each infant in each position. produced per minute plus 1 SD per test session.
Pediatric Physical Therapy Influence of Position on Leg Movements of Infants With Spina Bifida 383
Copyright © 2016 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
the frequency of leg movements observed in each position posited that stronger neural connections provide the basis
was impacted by the orthopedic impairments that 6 of the for stable movement patterns that are more likely to be
infants experienced as they completed this study. Another repeated over time. As a result, a seat similar to the SDIS
group of infants with SB who have fewer and/or less may be used to help infants with SB increase how often
severe orthopedic impairments, for example, infants with they kick, which would enable them to develop stronger
unilateral rather than bilateral club foot may demonstrate neural connections that support kicking behaviors and in-
less variability in how often they move their legs when in crease the probability that they would kick more often in
the supine position or seated in the SDIS. the future.8,9 Alternatively, if the goal is to simply increase
The observation that this group of infants with SB, how often infants with SB move their legs, then they could
despite the variability they demonstrated in chronological be placed in the supine position or in a position similar
age and motor development, were able to significantly in- to the SDIS and limit how often they are placed in a CS.
crease how often they moved their legs and kicked when These types of compensatory movement experiences may
they were seated in the SDIS is encouraging. This obser- enhance the ability of infants with SB to generate coordi-
vation is likely due to the fact that the SDIS facilitates the nated leg movements during their first year of life, which
infants’ ability to move their legs freely at the hips and may help them acquire more functional motor skills, such
knees. For example, when seated in the SDIS, they were as walking earlier in life, than in their current average age
able to move their legs medially and laterally. Medial and of 3 to 7 years.10-15
lateral leg movements appeared to be more difficult for
the infants to accomplish when they were seated in the Study Limitations
CS because of the lateral support the CS provides to the The significant position effect observed on the leg
infants’ legs. In addition, the CS allows the infants to sit movements and kicks generated by this group of infants
with their trunk, hips, and knees in a relatively flexed and should be interpreted cautiously. Only 9 infants with lum-
supported position, which may make it harder for them bar or sacral SB participated in this study. In addition,
to extend their legs at the hip and knee joints. It is also there was a 4.75-month chronological age range in this
possible that the SDIS provides a mechanical advantage group of infants who displayed considerable variability in
for leg movements and kicks compared with the CS and their motor development. It is possible that a larger group
the supine position. When seated in the SDIS, the infants’ of infants with a narrower age range and/or less variabil-
legs are flexed at the hips and knees. As a result, they are ity in their motor development may demonstrate different
able to produce leg movements and kicks that involve a rates of moving their legs and generating kicks. Although
relatively short lever arm, for example, the shank or lower the position order used in the current study replicated pre-
leg by “simply” flexing and extending their leg at the knee vious research, it was not randomized.4,5 It is possible that
joint. In comparison, when the infants are placed in the using a random position order may elicit different response
supine position, they generally have their legs extended at rates from infants with SB for leg movements and/or kicks.
the hips and knees, which requires them to move a much
longer lever arm than when they are seated in the SDIS. Recommendations for Future Studies

Clinical Implications Future studies could examine the effect specific in-
terventions have on the ability of infants with SB to move
The present results show for the first time that in- their legs and kick as well as describe the spontaneous leg
fants with lumbar or sacral SB who are 7 months and older movements and kicks of preambulatory infants with SB
are sensitive to the position in which they are placed and who are older than 11.5 months. Researchers and thera-
will increase or decrease the frequency of leg movements pists could also correlate the frequency of spontaneous leg
and kicks depending on the position. Parents and ther- movements and kicks with the onset of walking. The effect
apists may use these results to guide them as they plan, positional changes combined with enhanced sensory, for
implement, and evaluate the effect specific positions have example, visual, auditory, or kinesthetic, information have
on the ability of infants with lumbar or sacral SB to move on the ability of infants with SB to move their legs and kick
their legs and kick. For example, if the treatment goal is could also be examined in the future.
to enhance an infant’s ability to generate kicks, then they
should consider creating a movement situation like the
SDIS. The current data suggest that this type of infant seat CONCLUSION
may be used to increase how often older infants with lum- The purpose of this study was to describe the fre-
bar or sacral SB kick. This may be especially important quency with which infants with lumbar or sacral SB move
for infants with SB because they tend to spontaneously their legs and to kick when they are 7 months and older
move their legs and kick less often than infants who are while in the supine position, seated in a CS, and seated in a
TD.3-5 By enabling infants with SB to kick more often, they SDIS. This small group of infants with SB generated signif-
would be provided with additional opportunities to de- icantly more leg movements when seated in the SDIS than
velop coordinated leg movements and strengthen their leg they were seated in the CS and significantly more kicks
muscles as well as the neural connections that support their when seated in the SDIS than in the other 2 positions.
leg movements and kicks.3-5,7-9 Edelman and colleagues8,9 Thus, a movement context such as the SDIS may enhance

384 Chapman Pediatric Physical Therapy

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Unauthorized reproduction of this article is prohibited.
their ability to spontaneously move their legs and kick, 4. Chapman DD. Context effects on the spontaneous leg movements of
which may influence their ability to develop coordinated infants with spina bifida Pediatr Phys Ther. 2002;14:62-73.
5. Chapman DD. Context Effects on the Intrinsic Dynamics of Infants With
leg movements and strengthen their leg muscles as well as Spina Bifida (SB) [doctoral dissertation]. OCLC World Cat; 1997.
the neural connections that support their leg movements www.worldcat.org. Accessed July 25, 2015.
and kicks.3-5,8,9 6. Folio MR, Fewell RR. Peabody Developmental Motor Scales, 2 Ed.
(PDMS-2). San Antonio, TX: Pearson Inc; 2000.
7. Ulrich BD, Ulrich DA, Angulo-Kinzler RM, Chapman DD. Individual
ACKNOWLEDGMENTS differences in the intrinsic dynamics of leg movements in infants with
and without Down syndrome. Res Q Exerc Sport. 1996;68:10-19.
The author thanks the infants and their families for 8. Edelman GM. Neural Darwinism: The Theory of Neuronal Group
their participation and Rachel Katoch, Research Adminis- Selection. New York, NY: Basic Books Inc; 1987.
tration Staff Coordinator at Gillette Children’s Hospital in 9. Sporns O, Edelman GM. Solving Bernstein’s problem: a proposal for
the development of coordinated movement by selection. Child Dev.
St. Paul, Minnesota, who provided valuable assistance in 1994;64:960-981.
recruiting the infants and their families. 10. Ulrich BD, Ulrich DA. Spontaneous leg movements in infants
with Down syndrome and nondisabled infants. Child Dev. 1995;66:
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CLINICAL BOTTOM LINE

Commentary on “The Influence of Position on the Leg Movements and Kicks in Older Infants With Spina
Bifida”

“How should I apply this information?”

The evidence on how infants with spina bifida (SB) move their lower extremities in varied contexts is expanding.
This study reinforces basic concepts that apply to muscle strengthening and muscle testing. The results of this
study support the placement of infants with SB in positions that change the influence of gravity on weak muscles,
shorten the lever arm at the hips and knees, and allow for movement with less restriction from physical supports
such as a car seat. Physical therapists may apply this information by educating parents and caregivers on optimal
positioning for an infant with SB to promote increased movement.
“What should I be mindful about when applying this information?”
The findings from this study provide evidence for the positional effect on lower extremity movement for infants
with SB and possibly other diagnoses that lead to weak muscles. Further research is necessary to apply these
results to infants with other diagnoses and to make recommendations for specific interventions that correlate with
improved functional motor skills. A comprehensive description of the specially designed infant seat or alternative
options, in addition to the impact of sensory information on movement, would further guide application to
practice. Infants with SB and their families often receive early intervention services in their natural environments;
thus, parent education and methods to adapt commonly available items in the home to optimize positions are
important to integrate in daily routines.

Priscilla Weaver, PT, PhD, DPT, PCS

Early Intervention Provider & Bradley University
Peoria, Illinois
Gretchen Meyer, PT, MSEd
Michelle Yuen, PT, DPT
Easter Seals
Peoria, Illinois
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0000000000000306

Pediatric Physical Therapy Influence of Position on Leg Movements of Infants With Spina Bifida 385
Copyright © 2016 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.