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

380 Chapman Pediatric Physical Therapy

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Unauthorized reproduction of this article is prohibited.
METHODS
Institutional Review Board approval was obtained
for this prospective descriptive study prior to participant
recruitment. Participants were recruited through the
myelomeningocele clinic at a large metropolitan hospital
located in the upper Midwest. Their parents were informed
of the purposes of this study and provided written informed
consent before data were collected.
Description of Participants
Participants were 9 infants with lumbar or sacral SB.
They were recruited at 6.75 months or older, had a lumbar
or sacral spinal lesion due to SB, and were not walking.
Participants were born full-term except 1 baby was born
1 week prior to full-term. Infant age at entry was 6.75 to
11.5 months, with an average age of 8.75 ± 1.55 months.
Stationary motor ages, as assessed by the Peabody Develop-
mental Motor Scale–Second Edition (PDMS-2), was 1 to 10
months, with a mean of 6.22 ± 3.15 months. Locomotion
motor ages were from 3 to 8 months, with a mean of 5.11
months ± 1.83 months.6 Eight of the infants were born
via planned cesarean delivery. One infant had a spinal le-
sion repaired at 6 months of age, whereas the other infants
had their spinal lesions repaired during the first day of life.
Five infants had ventricular-peritoneal shunts and 1 infant
had a ventricular-atrial shunt placed before beginning this
study. None of the infants took medications that would
have impacted their ability to move their legs or kick. A
participation incentive of $10.00 was paid to each baby per
visit. Table 1 includes participants’ characteristics.
Movement Data Collection
Infants’ leg movements were videotaped at 30 Hz
(Sony HD Handycam). Two-dimensional data were col-
lected because the purpose of the study was to describe fre-
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
positioned up to a maximum of 2 m from and perpendic-
ular to the infants’ feet. This resulted in the optical axis of
the camera lens at an angle of approximately 22◦ with the
horizontal line of the floor when the camera was 2 m from
the infants’ feet.
Data were collected monthly for 4 consecutive months
at home. Before videotaping, the parent removed the baby’s
clothes to the infant’s diaper and tee-shirt. A reflective
hemispherical marker approximately 2.0 cm in diameter
was placed on the sole of each foot at the head of the first
metatarsal. These were attached with paper tape to avoid
allergic reactions.
Leg movements were videotaped for 2-minute trials
each in the supine position on a towel on the floor, seated
in a CS (Figure 1), and seated in the SDIS (Figure 2).
The order of position (supine, CS, SDIS) replicated
previous research, which demonstrated that moving from
the supine position to a more upright posture enabled
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.
Unauthorized reproduction of this article is prohibited.

Fig. 1. Conventional infant seat. The seat provides maximal sup-
port to the infant’s head, neck, trunk, and legs.
During testing, the parent(s) or author was seated near
the infant’s side and interacted with the infant visually and
socially. Each infant received a brief rest period between
conditions.
The difference between the CS and the SDIS is that
the SDIS is designed to provide firm support to the infant’s
head and trunk while allowing unrestricted leg movements
at the hips and knees. An elastic cloth positioned around
the infant’s chest and fastened with Velcro behind the back
support stabilized the trunk.
After videotaping during the first visit, the PDMS-2
was administered to obtain stationary and locomotion mo-
tor ages.6 These data provided descriptive information on
control of the body within the center of gravity, for exam-
ple, when sitting or moving, or crawling.6
Data Reduction
Video data were behavior coded frame by frame to
determine the onset and termination of leg movements for
each leg. These were defined as occurring when movement
of the marker stopped or started or when a change in
direction occurred.4,5,7 For example, if a baby moved his
or her leg laterally and then reversed direction and moved
Fig. 2. Specially designed infant seat. The seat positions the
infant’s trunk at an angle of 45◦ from the horizontal and pro-
vides firm support to the trunk and the head. The base of the
seat is 33 cm high, which prevents the infant’s feet from touch-
ing the support surface. An elastic cloth positioned around the
infant’s chest and fastened with Velcro behind the back support
is used to stabilize the infant’s trunk.
382 Chapman
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Unauthorized reproduction of this article is prohibited.
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
professional program assisted with coding. Students were
trained by the author to identify leg movements and each
type of kick. They coded a 2-minute trial to document
their ability to accurately identify leg movements and
kicks. They achieved a percent agreement with the author
of 80% or more before completing the coding.
Data Analysis
The data were analyzed using a 3 (Position) × 4 (Test
Session) multivariate analysis of variance (MANOVA),
with repeated measures for position and test session. The
dependent variables were the average number of leg move-
ments and kicks generated per minute. Significant main
effects, for example, position, were followed by univariate
tests, that is, leg movements or kicks, and pairwise com-
parisons for either position or test session as appropriate.
All statistical analyses were completed with SPSS software
(version 22), with the α level set at P = .05.
RESULTS
The average number of leg movements and kicks gen-
erated by this group of infants with SB in each position
per minute are presented in Figure 3. The 3 (Position) × 4
(Test Session) MANOVA, with repeated measures for po-
sition and test session revealed a significant position effect
(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.
Alternating leg kick The legs are flexing and extending at the
hips and knees in alternation.
Parallel knee kick Both knees are flexing and extending
simultaneously.
Parallel leg kick Both legs are flexing and extending at the
hips and knees simultaneously.
Pediatric Physical Therapy
Fig. 3. Average number of total leg movements and kicks pro-
duced in each position. The average number of total leg move-
ments and kicks produced per minute plus 1 SD in each position.
effect of position for the overall frequency of leg move-
ments (F2,16 = 5.285, P = .017, partial η2 = 0.398, and
observed power = 0.757) and kicks (F2,16 = 7.41, P =
.005, partial η2 = 0.481, and observed power = 0.888).
Infants generated significantly more leg movements
when they were seated in the SDIS than when they were
seated in the CS (P = .009). The frequency of leg move-
ments generated when they were in the supine position
versus when they were seated in the SDIS was not signif-
icant (P = .100). There were no significant differences in
the number of leg movements generated when the infants
were in the supine position compared with when they were
seated in the CS (P = .318).
Figure 4 illustrates the variability by subject in the
number of leg movements produced in each position. The
range of leg movements produced by the infants was small-
est in the CS, largest in the SDIS, and the most active baby
in one position was not necessarily the most active in an-
other, for example, infants 1, 2, and 8.
The infants generated significantly more kicks per
minute when they were seated in the SDIS than they were
seated in either of the other 2 positions, with single knee
kicks being the most common type of kick observed in
each position. Infants generated more kicks per minute,
on average, when they were seated in the SDIS than when
they were positioned in the CS (P = .016) and when they
were in the supine position (P = .033). There was not
a significant difference in the number of kicks they pro-
duced when in the supine position compared with when
they were seated in the CS (P = .587). Figure 5 illustrates
Fig. 4. Average number of leg movements produced in by each
infant in each position. The average number of total leg move-
ments generated per minute by each infant in each position.
Pediatric Physical Therapy Influence of Position on Leg Movements of Infants With Spina Bifida
Copyright © 2016 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
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Fig. 5. Frequency of types of kicks generated in each position.
The average number of each type of kick generated per minute
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.
how often this group of infants generated each type of kick
in each position.
There was not a significant test session effect on the
frequency of leg movements or kicks produced by this
group of infants in SB (Wilks λ = 0.846, F6,46 = 0.670,
P = .674). Figure 6 illustrates the average number of leg
movements and kicks produced per minute during each
test session.
DISCUSSION
The purpose of this study was to describe how often
infants with lumbar or sacral SB who were 7 months
and older moved their legs and kicked when they were
in the supine position, seated in a CS, and seated in a
SDIS. As expected, this group of infants with lumbar or
sacral SB moved their legs and kicked significantly more
often when they were seated in the SDIS than when they
were placed in the CS and generated significantly more
kicks when they were seated in the SDIS than when they
were in the supine position. They did not, however, move
their legs more often, on average, when they were in the
SDIS than when they were in the supine position. This
statistical outcome reflects the wide chronological age
range of the infants who participated in this study as well
as the range of their motor development as measured by
the PDMS-2.6 It is possible that a group of infants with SB
who showed less variation in their chronological age and
motor development may also demonstrate less variability
in how often they move their legs. It is also possible that
Fig. 6. Average number of leg movements and kicks produced
per test session. The average number of leg movements and kicks
produced per minute plus 1 SD per test session.
383
the frequency of leg movements observed in each position
was impacted by the orthopedic impairments that 6 of the
infants experienced as they completed this study. Another
group of infants with SB who have fewer and/or less
severe orthopedic impairments, for example, infants with
unilateral rather than bilateral club foot may demonstrate
less variability in how often they move their legs when in
the supine position or seated in the SDIS.
The observation that this group of infants with SB,
despite the variability they demonstrated in chronological
age and motor development, were able to significantly in-
crease how often they moved their legs and kicked when
they were seated in the SDIS is encouraging. This obser-
vation is likely due to the fact that the SDIS facilitates the
infants’ ability to move their legs freely at the hips and
knees. For example, when seated in the SDIS, they were
able to move their legs medially and laterally. Medial and
lateral leg movements appeared to be more difficult for
the infants to accomplish when they were seated in the
CS because of the lateral support the CS provides to the
infants’ legs. In addition, the CS allows the infants to sit
with their trunk, hips, and knees in a relatively flexed and
supported position, which may make it harder for them
to extend their legs at the hip and knee joints. It is also
possible that the SDIS provides a mechanical advantage
for leg movements and kicks compared with the CS and
the supine position. When seated in the SDIS, the infants’
legs are flexed at the hips and knees. As a result, they are
able to produce leg movements and kicks that involve a
relatively short lever arm, for example, the shank or lower
leg by “simply” flexing and extending their leg at the knee
joint. In comparison, when the infants are placed in the
supine position, they generally have their legs extended at
the hips and knees, which requires them to move a much
longer lever arm than when they are seated in the SDIS.
Clinical Implications
The present results show for the first time that in-
fants with lumbar or sacral SB who are 7 months and older
are sensitive to the position in which they are placed and
will increase or decrease the frequency of leg movements
and kicks depending on the position. Parents and ther-
apists may use these results to guide them as they plan,
implement, and evaluate the effect specific positions have
on the ability of infants with lumbar or sacral SB to move
their legs and kick. For example, if the treatment goal is
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
may be used to increase how often older infants with lum-
bar or sacral SB kick. This may be especially important
for infants with SB because they tend to spontaneously
move their legs and kick less often than infants who are
TD.3-5 By enabling infants with SB to kick more often, they
would be provided with additional opportunities to de-
velop coordinated leg movements and strengthen their leg
muscles as well as the neural connections that support their
leg movements and kicks.3-5,7-9 Edelman and colleagues8,9
384 Chapman
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posited that stronger neural connections provide the basis
for stable movement patterns that are more likely to be
repeated over time. As a result, a seat similar to the SDIS
may be used to help infants with SB increase how often
they kick, which would enable them to develop stronger
neural connections that support kicking behaviors and in-
crease the probability that they would kick more often in
the future.8,9 Alternatively, if the goal is to simply increase
how often infants with SB move their legs, then they could
be placed in the supine position or in a position similar
to the SDIS and limit how often they are placed in a CS.
These types of compensatory movement experiences may
enhance the ability of infants with SB to generate coordi-
nated leg movements during their first year of life, which
may help them acquire more functional motor skills, such
as walking earlier in life, than in their current average age
of 3 to 7 years.10-15
Study Limitations
The significant position effect observed on the leg
movements and kicks generated by this group of infants
should be interpreted cautiously. Only 9 infants with lum-
bar or sacral SB participated in this study. In addition,
there was a 4.75-month chronological age range in this
group of infants who displayed considerable variability in
their motor development. It is possible that a larger group
of infants with a narrower age range and/or less variabil-
ity in their motor development may demonstrate different
rates of moving their legs and generating kicks. Although
the position order used in the current study replicated pre-
vious research, it was not randomized.4,5 It is possible that
using a random position order may elicit different response
rates from infants with SB for leg movements and/or kicks.
Recommendations for Future Studies
Future studies could examine the effect specific in-
terventions have on the ability of infants with SB to move
their legs and kick as well as describe the spontaneous leg
movements and kicks of preambulatory infants with SB
who are older than 11.5 months. Researchers and thera-
pists could also correlate the frequency of spontaneous leg
movements and kicks with the onset of walking. The effect
positional changes combined with enhanced sensory, for
example, visual, auditory, or kinesthetic, information have
on the ability of infants with SB to move their legs and kick
could also be examined in the future.
CONCLUSION
The purpose of this study was to describe the fre-
quency with which infants with lumbar or sacral SB move
their legs and to kick when they are 7 months and older
while in the supine position, seated in a CS, and seated in a
SDIS. This small group of infants with SB generated signif-
icantly more leg movements when seated in the SDIS than
they were seated in the CS and significantly more kicks
when seated in the SDIS than in the other 2 positions.
Thus, a movement context such as the SDIS may enhance
Pediatric Physical Therapy
their ability to spontaneously move their legs and kick,
which may influence their ability to develop coordinated
leg movements and strengthen their leg muscles as well as
the neural connections that support their leg movements
and kicks.3-5,8,9
ACKNOWLEDGMENTS
The author thanks the infants and their families for
their participation and Rachel Katoch, Research Adminis-
tration Staff Coordinator at Gillette Children’s Hospital in
St. Paul, Minnesota, who provided valuable assistance in
recruiting the infants and their families.
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entropy values demonstrate impaired neuromotor control of spon-
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4. Chapman DD. Context effects on the spontaneous leg movements of
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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.