Physical & Occupational Therapy In Pediatrics

ISSN: 0194-2638 (Print) 1541-3144 (Online) Journal homepage: https://www.tandfonline.com/loi/ipop20

The Use of Dynamic Weight Support with

Principles of Infant Learning in a Child with
Cerebral Palsy: A Case Report

Samuel R. Pierce, Julie Skorup, Morgan Alcott, Meghan Bochnak, Athylia C.

Paremski & Laura A. Prosser

To cite this article: Samuel R. Pierce, Julie Skorup, Morgan Alcott, Meghan Bochnak, Athylia
C. Paremski & Laura A. Prosser (2020): The Use of Dynamic Weight Support with Principles of
Infant Learning in a Child with Cerebral Palsy: A Case Report, Physical & Occupational Therapy In
Pediatrics, DOI: 10.1080/01942638.2020.1766638

To link to this article: https://doi.org/10.1080/01942638.2020.1766638

Published online: 19 May 2020.

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PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS
https://doi.org/10.1080/01942638.2020.1766638

The Use of Dynamic Weight Support with Principles of

Infant Learning in a Child with Cerebral Palsy: A
Case Report
Samuel R. Piercea, Julie Skorupa, Morgan Alcotta, Meghan Bochnaka, Athylia C.
Paremskib, and Laura A. Prosserb,c
a
Department of Physical Therapy, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA;
b
Division of Rehabilitation Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA;
c
Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA

ABSTRACT ARTICLE HISTORY

Aims: Typical infant movement is characterized by a high degree of Received 25 November 2019
motor exploration, error, and variability. However, children with cere- Accepted 26 April 2020
bral palsy (CP) often cannot create these experiences due to their
KEYWORDS
neuromotor impairments. The purpose of this case study is to
Cerebral palsy; dynamic
describe a 6-month course of physical therapy (PT) incorporating weight support; motor
principles of infant motor learning using dynamic weight support learning; physical
(DWS) in a child with CP. therapy; toddler
Methods: The child was a 27-month-old girl with diplegic CP who
functioned at Gross Motor Function Classification System Level IV.
The child received 68 PT sessions over a six-month period. DWS was
used during therapy to encourage motor practice. The therapy area
was arranged to encourage active exploration, motor variability, and
error experience. Gross motor function, postural control, parent per-
ception of performance, and parent satisfaction were measured
before, during, and after the course of therapy.
Results: Gross motor function increased during the treatment
beyond the level predicted from natural progression. Postural control
fluctuated and demonstrated no appreciable improvement. Parent-
perceived performance and satisfaction improved on three of
four goals.
Conclusions: Using DWS to incorporate principles of infant learning
may have facilitated the development of gross motor skills in a child
with diplegic CP.

Cerebral palsy (CP) is the most common cause of physical disability in children (Pakula
et al., 2009). The best opportunity to maximize lifelong independence is early in motor
development when there is the most potential for neuroplastic change (Cioni et al.,
2011). In addition, the most effective rehabilitation programs for children with CP
include intense activity-based practice (Reid et al., 2015). Despite this evidence of an
early critical period for motor development, there remains sparse application of this

CONTACT Samuel R. Pierce pierces1@email.chop.edu Division of Rehabilitation Medicine, The Children’s Hospital
of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, USA.
ß 2020 Taylor & Francis Group, LLC
2 S. R. PIERCE ET AL.

knowledge to young children with CP and how best to optimize motor development in
this population remains unknown.
Many principles of effective neurorehabilitation training are also important compo-
nents of motor learning for infants who are developing typically. Typical infant move-
ment is characterized by immense amounts of practice and a high degree of motor
exploration (Adolph et al., 2012), error (de Graaf-Peters et al., 2007), and movement
variability (Adolph, 2008), which may be important factors in the development of motor
skill. However, infants and young children with CP often cannot create these movement
experiences on their own due to their neuromotor impairments. As a result, they have
limited opportunities to establish and refine the neural pathways that control
skilled movement.
One promising technology that may help to create an environment that encourages
movement exploration and variability and while allowing movement error is dynamic
weight support (DWS) (Hidler et al., 2011). DWS continuously provides the desired
amount of weight assistance through a harness as the child moves within the limits of
an overhead track system. For example, the child can sit, stand, walk, negotiate stairs,
transition between positions, squat to reach the floor, turn around to move in the
opposite direction, and even crawl, while the system maintains constant weight support
by controlling the variable length of the cable that joins the harness and track (i.e. cable
lengthens if child moves to the floor and shortens if child climbs up steps, with no lag
time). The child’s movements are not restricted so the system allows trunk movement
and errors. DWS, used in the context of motor learning principles that promote explor-
ation, variability, and error during movement, may allow toddlers with CP to have
motor learning experiences through playful discovery similar to peers with typical devel-
opment. In contrast, the application of treadmill training using body weight support
(Valentin-Gudiol et al., 2013) or robotics (Carvalho et al., 2017) in children with CP
limits movement to walking in a straight line and may prevent the experience of error
during movement, self-directed exploration, and movement variability which appear
critical to infant learning.
We have systematically developed and pilot-tested a novel intervention using DWS
designed to allow toddlers with CP to create for themselves motor learning experiences
more similar to peers with typical development (Prosser et al., 2012). Pilot work found
that four of five toddlers with CP demonstrated accelerated rates of motor development
during a 6-week program of physical therapy (PT) occurring three times per week
which used DWS and principles of infant motor learning. However, observations from
a longer training duration have not yet been reported. The purpose of this case report
was to describe a 6-month program of physical therapy using DWS to incorporate prin-
ciples of infant motor learning in a toddler with CP.

Case Description
The child was a 27-month-old girl with diplegic CP. She is classified at level IV on the
Gross Motor Function Classification System (GMFCS) (Palisano et al., 1997), and her
Gross Motor Function Measure-66 (Russell et al., 2013) score of 36.4 is at the 75th per-
centile for children her age classified as Level IV (Hanna et al., 2008). She had a history
 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS 3

of preterm birth after a 31-week gestation and spent four weeks in the NICU for
respiratory support. An MRI of her brain revealed periventricular leukomalacia. At the
baseline assessment, she was able to prop sit and commando crawl short distances but
was unable to attain quadruped, creep on hands and knees, or pull to stand. She
received early intervention PT one time per week and occupational therapy two times
per week, and these services remained in place during the 6-month clinic-based pro-
gram described here.
Outcome measures were administered in conjunction with a randomized controlled
clinical trial comparing a PT program emphasizing infant learning opportunities using
the dynamic weight assistance technology to conventional PT in toddlers with CP
(ClinicalTrials.gov Identifier: NCT02340026) (Prosser et al., 2018). This study was
approved by the Institutional Review Board of The Children’s Hospital of Philadelphia.
The child’s parent provided informed consent.

Therapy Sessions and Dynamic Weight Support System

The child was randomly assigned to the DWS group and received 68 PT sessions over a
6-month period which focused on training gait, balance, and other gross motor skills.
PT sessions were provided by three different physical therapists based on the family’s
availability for therapy. All therapists were trained in the use of DWS and infant learn-
ing principles by practicing with the device, participating in group case study discus-
sions, and reviewing videos from the pilot study. Therapy sessions were 30 minutes in
duration. The child’s mother was present for each session and participated during ses-
sions as needed to increase the child’s motivation.
Dynamic body weight support during PT sessions was provided using the ZeroGV R

Gait and Balance re-training system (Aretech LLC, Ashburn, VA, USA) located in a PT
gym which is approximately 900 square feet. The part of the track used for therapy for
this case is 15 feet long and allows for 3 feet of movement to either side (approximately
90 square feet total) and was above an area covered with therapy mats which was
arranged with toys selected from the child’s interests to encourage exploration and
scaled in difficulty level to encourage motor skills just beyond her current ability level.
The DWS harness was donned for all therapy time and provided a constant amount
of weight assistance, which was determined by the therapist. The amount of weight
assistance was set initially at 40% body weight support which was based on our pilot
experience. The amount of weight support was then set each session to the level at
which the child could stand and step with the least amount of assistance from the ther-
apist, but not to exceed 50%. Activities were graded in difficulty to the child’s ability
and included playing in quadruped, creeping on hands-and-knees, moving between the
floor and standing, walking with push toys, and other typical toddler play activities. The
therapist minimally assisted the child to perform the movements she initiated and
allowed high levels of movement exploration, variability, and error. No assistive devices
or orthotics were used during therapy sessions. See Figure 1 for a picture taken from a
typical PT session. The child moved an average of 313 feet per session (range of 38 to
572 feet). A median of 45.5% of body weight support was provided during each session.
See Table 1 for a description of a typical PT session.
4 S. R. PIERCE ET AL.

Figure 1. Photograph of the child playing with her physical therapist while in the dynamic weight
support device.

Table 1. Sample Therapy Session

Environment set up with high mat table, high bench, push toy, cause and effect toys, musical toys to encourage
crawling, kneeling, knee walking, transitions, standing, and walking
Child self-directing activities throughout session with focus on the following activities:
– Prone to/from quadruped with supervision
– Supine to/from sitting with close supervision to minimal assist
– Side sitting to/from kneeling at anterior surface, occasional minimal assist
– Kneeling and playing at surface
– Push to stand, multiple attempts
– Pull to stand at high mat table with close supervision
– Pull to stand at high mat table with one hand
– Cruising to right able to take three steps before loss of balance
– Side sitting with close supervision to one upper extremity prop
– Quadruped to/from kneeling at surface with close supervision to minimal assist
– Walking with push toy with close supervision to minimal assistance to turn, up to 10 steps
– Stepping 2–3 steps before loss of balance without upper extremity assistance

Outcome Measures
Measures of gross motor function, postural control, parent-perceived performance, and
parent satisfaction were collected prior to the start of the PT program (Assessment 1),
and after 6 weeks (Assessment 2), 12 weeks (Assessment 3), 18 weeks (Assessment 4),
and 24 weeks of intervention (Assessment 5). Additional follow-up measures were col-
lected 3 months, 6 months, and 12 months after the intervention but are not reported
here due to the patient receiving two separate series of botulinum toxin injections to
her bilateral lower extremities during the follow-up period. All measures were collected
by the same physical therapist who was not one of the treating therapists and was
blinded to the intervention.
The Gross Motor Function Measure (GMFM-66) (Russell et al., 2013) was completed
and includes a total score of gross motor function (GMFM-66) and scores for
Dimension B (sitting), Dimension C (crawling and kneeling), Dimension D (standing),
and Dimension E (walking, running, and jumping). The GMFM-66 is an interval-level
measure that accounts for difficulty of items, and a total score was calculated using the
 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS 5

Gross Motor Ability Estimator. Only the items from Dimension A (lying and rolling)
that were required for the calculation of the total GMFM-66 total score were adminis-
tered, while all items for the other dimensions were completed. Dimension scores are a
simple percentage of the total raw score and do not account for difficulty. They were
calculated using the instructions for the GMFM-88.
The method described by Duran et al. (2019) was used to assess the effect size for
GMFM scores. Briefly, the reference centiles of Duran et al. (2019) were used to deter-
mine the z scores for the GMFM-66 at 27 months of age and 33 months of age, which
corresponds to our baseline period and after 24 weeks of intervention. Next, the z score
after 24 weeks of intervention was subtracted from the z score at baseline and then div-
ided by the standard deviation of the centile change to obtain an estimate of the effect
size of the intervention.
The Early Clinical Assessment of Balance (ECAB) (McCoy et al., 2014) assesses head
and trunk control in response to postural challenges and the ability to maintain balance
during sitting, standing, and other motor activities. The reliability and validity of the
ECAB (McCoy et al., 2014; Randall et al., 2014) have been supported in children
with CP.
Caregiver satisfaction was measured with the Canadian Occupational Performance
Measure (COPM) (Law et al., 2014) which uses client- or family-generated goals to rate
performance and satisfaction with performance in the achievement of goals for inter-
vention (Cusick et al., 2007). The child’s mother set goals at baseline based on her pri-
orities and without the PT influencing the goals or providing feedback on how likely
the PT felt the goal would be achieved during the study period. The child’s mother then
rated their child’s performance at each assessment on a scale of 1 (not able to do it) to
10 (able to do it extremely well) and their satisfaction with the child’s performance
toward these goals on a scale of 1 (not satisfied at all) to 10 (extremely satisfied) at each
assessment session.

Outcomes
The child’s outcomes in gross motor function and postural control are presented in
Table 2. The GMFM-66 score increased from 36.4 to 42 over 6 months; the estimated
effect size calculated using Duran’s method was 1.2 indicating a large effect.
Performance in all GMFM activity dimensions increased during the study period with
the largest gains in Dimension C (crawling and kneeling). Examples of independent

Table 2. Gross Motor Function and Postural Control Outcomes

Session Total GMFM-66 GMFM B GMFM C GMFM D GMFM E ECAB
Baseline 36.4 38.3 7.1 2.6 4.2 26.5
6-week PT 39.7 58.3 14.3 5.1 5.6 30.5
12-week PT 40.4 53.3 19 7.7 5.6 25.5
18-week PT 40.7 65 19 7.7 5.6 32.5
24-week PT 42 65 23.8 7.7 9.7 29.5
GMFM: Gross Motor Function Measure.
B: Dimension B – Sitting.
C: Dimension C – Crawling and kneeling.
D: Dimension D – Standing.
E: Dimension E – Walking, running, and jumping.
ECAB: Early Clinical Assessment of Balance.
6 S. R. PIERCE ET AL.

Table 3. Canadian Occupational Performance Measure Outcomes

Would like her to run Would like her to move Would like her to sit
Would like for her to outside and play with at home to have to and stand
Goal walk independently the dogs child proof the home independently
Session P S P S P S P S
Baseline 2 1 1 1 1 1 3 3
6 weeks 1 4 1 1 1 4 2 5
12 weeks 2 2 1 1 6 8 5 5
18 weeks 1 4 1 2 6 10 5 7
24 weeks 4 3 1 1 9 10 7 6
P ¼ Parent-perceived performance.
S ¼ Parent satisfaction with child’s performance.

motor skills that the child gained during the study period included the ability to creep
forward 6 feet in prone, maintain sitting on the mat with arms free, and maintain a
four-point position with her weight on her hands and knees for 10 seconds. In addition,
the child was able to initiate new motor skills, such as cruising to the right, cruising to
the left, and walking with one hand held at the end of the study which she was unable
to perform at baseline.
The improvements in ECAB scores between baseline and the 24-week assessment
were smaller than the minimally detectable change score for the test which is reported
as 10 points (Randall et al., 2014). Scores varied throughout the study period and dem-
onstrated no appreciable improvement. Finally, parental report of child performance
and parent satisfaction with the parent’s goals using the COPM improved from baseline
to the 24-week assessment for three of four goals by 2 or more points, which is the
reported value for clinically meaningful change by Wallen and Ziviani (2012). See Table
3 for COPM outcomes.

Discussion
The purpose of this case report was to describe a 6-month program of physical therapy
using DWS to incorporate principles of infant motor learning with a toddler with CP.
The child demonstrated improvements in all dimensions of the GMFM, and it is note-
worthy that the effect size for the GMFM-66 score was large as calculated by the predict-
ive model of Duran et al. (2019). The intervention period was longer (6 vs. 24 weeks),
and the total change observed was larger than in our previous work using DWS, despite
the child having more severe motor impairment, which may suggest a dose effect. The
child in our case was classified at GMFCS level IV and demonstrated a total change of
5.6 points over 6 months, but more than half of this change (3.3 points) occurred in the
first 6 weeks. This is consistent with the three children in our previous work who were
classified at GMFCS level III and demonstrated changes ranging from 3.3 to 4.6 points
over 6 weeks. Despite a larger total gain, the average rate of change was smaller in this
child compared to our previous work, which may be attributed either to her lower motor
ability or to the dose-response trajectory with greater gains in the early weeks of therapy.
Better understanding of dose-response trajectories and how to select the most optimal
time for this intervention will further guide treatment and require additional study.
The child’s parent reported improvement in performance and satisfaction for three of
four self-identified COPM goals, which showed clinically meaningful changes during
 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS 7

the treatment period. The COPM goals in which she demonstrated clinically significant
improvement were related to walking (“would like for her to walk independently”),
moving within the home (“would like her to move at home to have to child proof the
home”), sitting, and standing (“would like her to sit and stand independently”). Aspects
of these activities were frequently practiced during therapy sessions (see Table 1) which
were observed by the child’s parent which may have led to the improvements in COPM
scores. In addition, the one COPM goal that was not achieved (“would like her to run
outside and play with the dogs”) may not have been realistic due to her motor level at
the start of the intervention.
The lack of measureable change in the ECAB scale for postural control is surprising,
given the changes in gross motor function and our prior work supporting the test’s
responsiveness to change (Pierce et al., 2018). However, the effect of DWS on posture
has not been reported so that is it unknown if DWS is beneficial or detrimental to pos-
tural control. In addition, our intervention using DWS was focused on gross motor
skills and not postural control which may be an explanation why postural control did
not improve with the intervention.
While it is unknown what the contribution of outside therapies was to the subject’s
improvements, our program of DWS which incorporated principles of infant learning
may have facilitated her gross motor skill development. DWS allowed the child to per-
form activities which she was unable to complete on her own or with less help that she
typically required, which allowed her additional practice opportunities. Other technolo-
gies using treadmill training with static body weight support (Valentin-Gudiol et al.,
2013) or exoskeletons (Carvalho et al., 2017) do not allow the child to practice activities
other than walking in a straight line, which is not how infants learn to move. We used
DWS as a tool to incorporate principles of infant motor learning, while physical thera-
pists can use principles of infant motor learning with a variety of strategies for treat-
ment that do not require the specific use of DWS. Interestingly, Ryan et al. (2019)
recently reported the use of similar motor learning strategies when using both a robotic
gait training system and traditional gym-based gait interventions. The relative contribu-
tion of using the principles of infant motor learning versus the DWS technology would
be an interesting topic of future research.
The issue of identifying when children with CP would benefit most from interven-
tions such as DWS is a critical area for future research. Since children with typical
development may develop their motor skills with periods of improving motor perform-
ance followed by a plateau period of stable motor skills (Darrah et al., 1998), our inter-
vention may have been timed by chance during a period in which the child was ready
to learn new skills or may have facilitated the learning of new skills through the use of
DWS technology allowing an increased variety of motor activities. We did not assess
carryover of new motor skills into the home environment so that it is unknown how
the incorporation of infant motor learning skills through a clinic-based physical therapy
intervention affects motor behavior at home.
This issue of carryover of new motor skills into the home environment would be an
important topic for research investigating incorporation of infant motor leaning princi-
ples either with or without the use of DWS technology. Finally, the matching of individ-
ual concepts of motor learning, such as exploration, variability, and error during
8 S. R. PIERCE ET AL.

movement, to the selected motor tasks during therapy was not tracked during this case
study. Research investigating the alignment of principles of motor learning to selected
motor activities during physical therapy would be a valuable contribution to
the literature.
The optimal amount of DWS that is most effective in facilitating learning of new
gross motor skills in children with CP is unknown. A review by Apte et al. (2018)
reported that kinematic, kinetic, and temporal spatial characteristics of gait in adults
with and without neurological injuries were influenced by the amount of body weight
and recommended using less than 30% body weight support to achieve task-specific gait
training. In this investigation, our average level of body weight support was 40.5% and
determined by the treating physical therapists to allow the most independence in self-
directed gross motor skills. A major difference between our study and the existing lit-
erature is that our subject was completing a variety of gross motor activities while
receiving DWS and the focus of PT intervention was not only walking. It is unknown
whether either increasing or decreasing the amount of weight support would have
caused greater improvements in gross motor skills. The short-term and long-term
effects of different amounts of DWS in toddlers with CP on walking and other gross
motor skills are unknown and require additional research.

Acknowledgments
We offer special thanks to the child and his family who participated in this study.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This research was supported by the National Institute on Disability, Independent Living, and
Rehabilitation (H133G140166).

Notes on contributors
Samuel R. Pierce, PT, PhD, NCS, is a physical therapist at The Children’s Hospital of
Philadelphia and a Board Certified Clinical Specialist in Neurologic Physical Therapy. He works
in multidisciplinary clinic settings with a special focus on children with neurogenetic disorders.
His research interests include the assessment of development in children with neuro-
logical disorders.
Julie Skorup, PT, DPT, PCS, is a physical therapist at The Children’s Hospital of Philadelphia
and a Board Certified Clinical Specialist in Pediatric Physical Therapy. She works in outpatient
and multidisciplinary clinic settings with a special focus on children with cerebral palsy.
Morgan Alcott, PT, DPT, PCS, is a physical therapist at The Children’s Hospital of Philadelphia
and a Board Certified Clinical Specialist in Pediatric Physical Therapy. She works in outpatient
and multidisciplinary clinic settings with a special focus on children with cerebral palsy.
Meghan Bochnak, PT, DPT, PCS, is a physical therapist at Rady Children’s Hospital in San
Diego, CA and a Board Certified Clinical Specialist in Pediatric Physical Therapy.
 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS 9

Athylia C. Paremski, BA, is a clinical research assistant in the Division of Rehabilitation

Medicine at The Children’s Hospital of Philadelphia.
Laura A. Prosser, PT, PhD, is a pediatric physical therapist in the Division of Rehabilitation
Medicine at The Children’s Hospital of Philadelphia and an Assistant Professor in the
Department of Pediatrics at the University of Pennsylvania.

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