Robin L. Dole PT DPT EdD PCS, Ross Chafetz PT DPT MPH - Peds Rehab Notes - Evaluation and Intervention Pocket Guide (Davis's Notes Book) - F.A. Davis Company (2010)

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Peds Rehab
Notes
Evaluation and Intervention Pocket Guide
Robin L. Dole, PT, DPT, EdD, PCS

Ross Chafetz, PT, DPT, MPH
Purchase additional copies of this book at your
health science bookstore or directly from F.A. Davis
by shopping online at www.fadavis.com or by
calling 800-323-3555 (US) or 800-665-1148 (CAN)
A Davis’s Notes Book

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F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2010 by F. A. Davis Company
Copyright © 2010 by F. A. Davis Company. All rights reserved. This product is protected by copy-
right. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form
or by any means, electronic, mechanical, photocopying, recording, or otherwise, without writ-
ten permission from the publisher.
Printed in China
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
Acquisitions Editor: Margaret M. Biblis

Manager of Content Development: George W. Lang
Senior Developmental Editor: Jennifer A. Pine
Art and Design Manager: Carolyn O’Brien
Reviewers: Barbara J. Bour, PT, Stephen Carp, PhD, PT, GCS, Donna Cech, PT, PhD, Ellen
Godwin, PT, PhD, PCS, Suzanne Giuffre, PT, EdD, PCS, Mary Hallway, OTR/L, Kimberly B.
Harbst, PT, PhD, Patricia A. Hodson, PT, DPT, PCS, Hélène M. Larin, PT, PhD, Karla Laubenthal,
PT, MS, PCS, Janet Audrey MacDonald, Jennifer A. Mai, PT, DPT, MHS, NCS, Mary Elizabeth
Parker, PT, MS, PCS, Brenda Pratt, PT, MS, PCS, Nora Riley, PT, MA, NCS, Joellen Roller, PT, DPT,
EdD, Linda J. Tsoumas, PT, MS, EdD, Tawna Wilkinson, DPT, PT
As new scientific information becomes available through basic and clinical research, recom-
mended treatments and drug therapies undergo changes. The author(s) and publisher have
done everything possible to make this book accurate, up to date, and in accord with accepted
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for errors or omissions or for consequences from application of the book, and make no war-
ranty, expressed or implied, in regard to the contents of the book. Any practice described in this
book should be applied by the reader in accordance with professional standards of care used
in regard to the unique circumstances that may apply in each situation. The reader is advised
always to check product information (package inserts) for changes and new information regard-
ing dose and contraindications before administering any drug. Caution is especially urged
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ADVOCACY EXAM/EVAL DX LABS MEDS INTERVEN O&P AT

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1
Americans with Disabilities Act (ADA)
Title III—Key Components for Inclusion
of Children with Disabilities
Regulations extend to public and private schools and non–publicly funded
programs such as child care centers, preschools, before and after school
programs, and other community programs.
■ Centers cannot exclude children with disabilities from their programs
unless their presence would pose a direct threat to the health or safety
of others or require a fundamental alteration of the program.
■ Centers have to make r e a s o n a b l e m o d i f i c a t i o n s to their policies and
practices to integrate children, parents, and guardians with disabilities
into their programs unless doing so would constitute a fundamental
alteration.
■ Centers must provide appropriate auxiliary aids and services needed
for effective communication with children or adults with disabilities
when doing so would not constitute an undue burden.
■ Centers must generally make their facilities accessible to individuals
with disabilities. Existing facilities are subject to the readily achievable
standard for barrier removal, whereas newly constructed facilities and
any altered portions of existing facilities must be fully accessible.
■ Publicly funded programs such as Early Head Start and Head Start
may not exclude children with disabilities, provided that they meet
the criteria for inclusion, such as family income level.
■ Practitioners should inform families and facilities of the ADA regula-
tions and assist in recommending appropriate accommodations to
aid in inclusion.
Individuals with Disabilities Act (IDEA)

Rights of Children and Families
■ Zero reject
■ To qualify under this law, the child must have one of the 13 qualify-
ing disabilities, and that disability must impact the child’s education.
■ All children regardless of severity of disability are provided with an
education.
ADVOCACY
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ADVOCACY
■ Least restrictive environment

■ Children should be educated in the same settings as typical
age-matched peers to the maximum extent possible.
■ Right to due process
■ Parents have the right to an impartial hearing, the right to represen-
tative counsel, and a right to a transcript of the meetings.
■ Nondiscriminatory evaluation
■ All tests and measures must not be biased to race or culture and
must be given in the child’s native language when necessary.
■ Parent participation
■ Parents are encouraged to participate in the educational plan for
their child; they also have the final power of acceptance or may
appeal.
■ Related services
■ IDEA provides for the special education and related services that
are needed for a child to obtain FAPE (see later).
■ These services include occupational therapy, physical therapy, and
speech and language therapy, audiology, transportation, orientation
and mobility, and medical diagnostic services for evaluation only.
■ “Free and Appropriate Education” (FAPE) for children with disabilities
■ IDEA—Part C
■ P u r p o s e : To enhance the development of infants and toddlers with
disabilities, to minimize their potential for developmental delay,
and to recognize the significant brain development that occurs
during a child’s first 3 years of life.
■ D o c u m e n t a t i o n : The IFSP (Individual Family Service Plan/Program)
is a family-led document that includes areas of strengths, needs,
resources, major outcomes, steps to achieve outcomes, and dates
established and reviewed. The IFSP must be reviewed at a minimum
every 6 months.
■ IDEA—Part B
■ P u r p o s e : To provide funding to states (and local education agencies)
for children 3–21 years old who require special accommodations to
receive a “free and appropriate” education.
■ D o c u m e n t a t i o n : The IEP (Individual Education Plan/Program) is
an educational plan to meet the learning needs of the identified
child. It includes the child’s present level of performance, annual
goals (and objectives if applicable), specially designed instructions,
2
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3
related services, and extent to which child participates with nondis-
abled peers. The major difference between the IFSP and IEP is that
the focus shifts from family-focused to child-focused as it pertains
to the child’s abilities. IEP must be reviewed at a minimum every
year. Multiyear IEPs are permitted in some states.
Rehabilitation Act of 1973—Section 504

■ Antidiscrimination act: Protects qualified individuals from discrimina-
tion based on disability
■ Qualified individuals are those who can perform the essential func-
tions of the job or role (e.g., student) with or without reasonable
accommodations.
■ Applies to any employer or organization that receives any type of
federal funding
■ Can be applied to children with disabilities to prevent denial of services
or access to environments related to their education
■ Practitioners may become involved in creating and providing reason-
able accommodations
Assistive Technology Act

■ Provides federal funding to state programs that were created to meet
the assistive technology needs of individuals with disabilities
■ Many programs provide assistive technology lending libraries, profes-
sional and technical support, and professional development
■ Look up your state’s program at:
http://www.resna.org/content/index.php?pid=133
Health Insurance Portability

and Accountability Act (HIPAA)
Patient Protection
■ Access to medical records
■ Provide access to records within 30 days
■ May charge for copies or sending records
ADVOCACY
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ADVOCACY
■ Notices of privacy practices

■ Must provide patients with notice of patient’s rights and how personal
medical information may be used
■ Limits on use of personal medical information
■ Does not restrict ability of providers to share information needed to
treat patients
■ May not be used for purposes unrelated to health care (e.g., life
insurance) without patient’s written consent
■ Prohibition on marketing
■ Limits use of patient information for marketing purposes
■ Stronger state laws
■ States may develop stronger privacy requirements
■ Confidential communication
■ Patients can request specific means of communication methods to
ensure privacy (e.g., call only at office rather than home, no voice mail)
■ Complaints
■ Patients can file complaints directly with the provider or with the
HHS Office of Civil Rights (OCR)
Health Plans and Providers

■ Written privacy procedures
■ Providers and Plans must have written policies and procedures.
■ Employee training and privacy officer
■ Employees must be trained and have a designated person to
ensure compliance.
■ Public responsibilities
■ Equivalent requirements for government
Child Abuse Prevention and Treatment and

Adoption Act (CAPTA) as Amended by the
Keeping Children and Families Safe Act
Each state is required to have a system for reporting suspected child
abuse and neglect. Check specific regulations for more information. Some
professional licensure bodies require licensees to be mandatory reporters
of child abuse. Consult the following governmental Website for more
information: http://www.childwelfare.gov/systemwide/laws_policies/state/
4
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Common Signs of Child Abuse and Neglect
■ Physical abuse
■ Burns
■ Cuts
■ Bite marks
■ Welts in the shape of any object
■ Fractures
■ Head injuries
■ Internal injuries
■ Sexual abuse
■ Inappropriate interest or knowledge of sexual acts
■ Seductiveness
■ Fear of a particular person
■ Neglect
■ Extreme hunger/malnourishment
■ Medical neglect
■ Educational neglect
■ Inappropriate clothing for weather/dirty and unkempt
Governmental Benefits for Disabled Children

■ Supplemental Security Income—payments to a disabled child
(<18 years old); based on income level
■ Social Security Disability Insurance—for adults who have been
disabled since childhood
■ Medicaid—insurance program for individuals with limited income; in
some states children with disabilities can qualify
Selected Internet Resources for Advocacy

■ United States Department of Health and Human Services:
■ Administration for Children and Families
http://www.acf.hhs.gov/programs/cb/
■ Families and Children information page
http://www.hhs.gov/children/index.shtml
ADVOCACY
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ADVOCACY
■ Physical Activity Guidelines for Americans: Active Children and

Adolescents
http://www.health.gov/paguidelines/guidelines/chapter3.aspx
■ Office of the Surgeon General: Childhood Overweight and Obesity
Prevention Initiative
http://www.surgeongeneral.gov/obesityprevention/index.html
■ Centers for Medicare and Medicaid Services: Children’s Health
Insurance Program
http://www.cms.hhs.gov/home/chip.asp
■ Health Resources and Services Administration: Maternal and Child
Health Bureau
http://mchb.hrsa.gov/
■ Child Welfare Information Gateway
http://www.childwelfare.gov/
■ National Mental Health Information Center: Child and Adolescent
Mental Health
http://mentalhealth.samhsa.gov/child/childhealth.asp
■ State Children’s Health Insurance Programs
■ http://www.ncsl.org/programs/health/chiphome.htm
■ http://www.insurekidsnow.gov/states.asp
■ Children’s Defense Fund
■ http://www.childrensdefense.org/
6
Page 7
Diagnosis Prognosis
• Process of evaluating exam data • Determine level of optimal improvement
• End result of process that leads to: • Estimate amount of time and number of
• Organization into clusters, syndromes, visits to reach that level
Patient-Client Management Model
categories • Plan of care – including interventions, and

• Determination of prognosis and plan their timing and frequency
4:39 PM
of care
Intervention
Evaluation • Coordination,
3/11/10
• Clinical judgements communication, and

based on exam data documentation
• ID problems that may • Patient/client-related
require consult or referral instruction
7
• Procedural interventions
1815_Tab02_007-098.qxd
Outcomes
Examination
• Impact of interventions on
Data gathering from:
all elements of the ICF
• History
• Includes risk reduction,
• Systems review
EXAM/EVAL
prevention, patient/client
• Tests and measures
satisfaction
Adapted from American Physical Therapy Association. Guide to physical therapist practice (2nd ed). Physical Therapy. 81(1).
Copyright 2001 by the American Physical Therapy Association.
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EXAM/EVAL
History Taking—Relevant Items

Past Medical History/Birth History
■ Significant medical history of biological parents
■ Mother’s history related to pregnancy, labor, delivery
■ Child’s history related to pregnancy, labor, delivery
■ Significant medical history of relatives including siblings
■ General health status
■ History of major childhood/adolescent illnesses
■ History of any surgical or medical procedures
■ Known allergies to food, medications, substances, etc.
■ Neonatal screening and immunization history
■ Diagnostic or medical tests related to past history
Current Medical History

■ Current sign and symptoms
■ Onset, duration, and severity of presenting problem
■ Current health-care practitioners involved with child’s care (includes
physicians, therapists, psychologists, orthotists, etc.)
■ Current medications—purpose, dosage, history of adverse reactions
■ Date and, if available, results of recent medical and diagnostic testing
■ Current and planned medical and surgical interventions
■ Current functional and activity levels
■ Use of adaptive equipment or devices
Developmental History
■ Infant/child temperament
■ Child/caregiver interactions
■ Growth and nutrition (including rate of growth in height, weight, head
circumference; timing of tooth eruption)
■ Feeding—daily routine, preferences, difficulties
■ Achievement of major milestones (including sensorimotor, social-
emotional, cognitive, language, self-care, etc.)
■ Bowel and bladder control/toilet training
8
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Social History
■ Parents/caregivers’ employment status
■ Home layout and environment (including safety issues/childproofing;
exposure to lead, tobacco, or other hazards)
■ Sleep routine, child’s sleeping position
■ Use of car seat
■ Child care and school history
■ Signs of abuse and neglect
Systems Review/Basic Screening

Cardiovascular-Pulmonary System*
■ Vital signs: Heart rate, respiratory rate, blood pressure, temperature,
pain
■ Observation: Difficulty breathing or crying, excessive crying, cyanosis,
retractions, nasal flaring, cough, response to change in position,
activity; fatigue, weight loss or gain
■ Palpation: Peripheral pulses, tactile fremitus
■ Auscultation: Heart and lung sounds
■ Percussion: Any areas of dullness over lung fields
*see Examination of Cardiovascular-Pulmonary System for more
details.
Neuromuscular System*
■ Newborns: APGAR, gestational age, birth weight; suck and swallow;
irritability/consolability, state regulation
■ Observation: General resistance to passive movement; is it velocity-
dependent?
■ Observation: Ability to make eye contact and track objects
*see Examination of Neuromuscular System for more details.
EXAM/EVAL
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EXAM/EVAL
Musculoskeletal System*
■ Anthropometrics: Height, weight, head circumference
■ Observation: Size and shape of head, face, skull; any abnormalities of
eyes, ears, nose, mouth, palate, teeth; skeletal asymmetry; swelling,
bruising
■ Complaints: Pain; refusal to bear weight, walk, move; fever; night pain
*see Examination of Musculoskeletal System for more details.
Integumentary System*
■ Observation/palpation: Texture, temperature, color and pigmentation,
scarring, presence of hair, turgor/hydration, swelling
■ Observation: Presence of skin lesions, rash, skin infection, change in a
mole (color, size, shape, pain, itching, bleeding)
*see Examination of Integumentary System for more details.
Endocrine System
■ Complaints: Increased thirst, frequent urination (especially at night),
decreased activity, persistent constipation or diarrhea, increased
sweating, hunger or decreased appetite, headache, dizziness or light-
headedness, emotional lability, alterations to menstrual cycle
■ Observation: Short stature, precocious puberty, swollen gums, delayed
healing time with typical sores/abrasions, weight loss or gain
Gastrointestinal System
■ Complaints: Nausea, vomiting, fever, reflux, colic, abdominal pain,
chronic hunger or refusal to eat, abnormal stools or diarrhea, change
in urine/output
■ Observation: Excessive mucus in mouth and nose, posturing/neck
extension or movement of head during feeding, signs of dehydration,
weight loss or gain
10
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Lymphatic/Immune System
■ Complaints: Fever, sore throat, rash, general malaise, night sweats,
joint swelling or pain, weight loss
■ Palpation: Lymph nodes (neck, clavicular area, axilla, groin), spleen
(1–2 cm below left costal margin), liver (≤ 2cm below right costal
margin)—check for enlargements
Palpation of Lymph Nodes, Spleen, and Liver

Posterior
Preauricular
auricular
Occipital Superifical cervical
Maxillary
Posterior cervical
Subclavicular Sublingual
Axillary Submandibular
Liver
Spleen Supraclavicular
Superficial
inguinal
(inferior and
medial)
Superficial
inguinal
(superior and
lateral)
Popliteal
(behind knee)
Notes: Check size, location, pain, consistency; palpable nodes in children

can be normal (mobile, soft, nontender), but if >10 mm should be evalu-
ated; enlarged nodes in supraclavicular, iliac, and popliteal regions are
never normal; most common cause of lymphadenopathy in children is
infection, e.g., otitis media, pharyngitis.
EXAM/EVAL
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EXAM/EVAL
Genitourinary System
■ Complaints: Problems or changes in bowel/bladder function; frequent
UTI; fever; vomiting; chills; abdominal pain; pain with urination;
referred pain patterns to low back, flank, inner thigh, leg, ipsilateral
shoulder; alterations to menstrual cycle
■ Observation: Fluid retention, dehydration, weight loss or gain, edema,
irritability, unusual odor, discharge, signs of abuse
■ Vital signs: Blood pressure, temperature (fever)
Examination—General Information
■ Reason for referral/primary complaints/strengths and needs—sample
questions for child and family
■ What brings you to this visit, what do you hope to gain from this visit?
■ What problems are you experiencing that have led to this visit?
■ What do you enjoy doing? What do you enjoy doing with your
child? What does your child like to do?
■ What things are difficult for you to do? What things are difficult for
you to do with your child?
■ What would help you to improve? What would help your child improve?
■ Behavioral responses to various situations/contexts
■ Daily routine
■ Sleeping patterns
■ Feeding patterns; amounts, types, and textures of foods/liquids
■ Play
■ Orientation (to person, place, time)/memory
Children’s Orientation and Amnesia Test (COAT)

General Orientation (for ages 3–15 yr) Max. Score
What is your name? 2 pts = first name 5
3 pts = last name
How old are you? 3 pts 5
When is your birthday? 1 pt = month
1 pt = year
Continued
12
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Children’s Orientation and Amnesia
Test (COAT)—cont’d
General Orientation (for ages 3–15 yr) Max. Score
Where do you live? 3 pts = city 5
2 pts = state
What is your father’s name?
What is your mother’s name?
What school do you go to? 3 pts 5
What grade are you in? 2 pts
Where are you now? OR 5 pts 5
Are you home now? Are you Must answer both
in a hospital? correctly to = 5 pts
Is it daytime or nighttime? 5 pts 5
Total
Children’s Orientation and Amnesia Test (COAT)

Temporal Orientation (for ages 8–15 yr) Score
What time it is now? 5 pts if correct 5
4 pts <1 hr off
3 pts if 1 hr off
2 pts >1 hr off
1 pt if 2 hr off
What day of the week is it? 5 pts if correct 5
4 pts if 1 day off
3 pts if 2 days off
2 pts if 3 days off
1 pt if 4 days off
What day of the month is it? 5 pts if correct 5
4 pts if 1 day off
3 pts if 2 days off
2 pts if 3 days off
1 pt if 4 days off
Continued
EXAM/EVAL
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EXAM/EVAL
Children’s Orientation and Amnesia

Test (COAT)—cont’d
Temporal Orientation (for ages 8–15 yr) Score
What month is it? 10 pts if correct 10
7 pts if 1 mo off
4 pts if 2 mo off
1 pt if 3 mo off
What is the year? 5 pts if correct 15
7 pts if 1 mo off
4 pts if 2 mo off
1 pt if 3 mo off
Total
Memory Score
Say these numbers after me For each of seven 14
and in the same order groups:
• 3 5 2 pts if both correct
• 58 42 1 pt if only one correct
• 643 926 d/c if fail both series of
• 7216 3279 any length
• 35296 81493
• 539418 724856
• 8129365 4739128
How many fingers am I 2 pts = correctly IDs 10
holding up? 2 fingers
3 pts = correctly IDs
3 fingers
5 pts = correctly IDs
10 fingers
Who is on Sesame Street 10 pts 10
(or other major/relevant
TV show)?
What is my name? 10 pts 10
Total
Overall Total
Source: Ewing-Cobbs, L., Levin, H.S., Fletcher, J.M., Miner, M.E., and Eisenberg, H.M.: The children’s
orientation and amnesia test: Relationship to severity of acute head injury and to recovery of
memory. Neurosurgery. 1990; 27:683–691.
14
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■ Cognition—examples of quick screening and tools by age:
■ Infant—eye contact, interest in people and environment, object
permanence, cause/effect, seeks caregiver; BINS—Bayley Infant
Neurodevelopmental Screener (3–24 mo; 5–10 min; 11–13 items;
screens neurological, cognitive, auditory, visual, motor, and verbal
responses)
■ Toddler—points and names objects/body parts, knows own name,
follows simple directions, simple problem-solving; SCCIT—Screening
for Communication and Cognition in Infants and Toddlers (6–24 mo;
5 minimum; 18 questions; detects concerns that warrant further
referral)
■ Preschooler—makes needs and wants known, recognizes
approval/disapproval, progression of play skills, ASQ—Ages and
Stages Questionnaire (0–60 mo; 10–15 min; 30 items; screens
language, person-social, motor, and cognition)
■ School-age child—performance in school (on grade level?),
SYSTEMS—School-Years Screening Test for the Evaluation of
Mental Status (5–12 yr; 7–12 min; 46 questions; screens for suspected
cognitive problems or changes)
■ Adolescent—performance in school (on grade level?), BRIEF—
Behavior Rating Inventory of Executive Function (5–18 yr; 10–15
min; 87 items; screens for self-control and problem-solving skills)
■ Communication/language/speech production—primary language of
child and family; methods of communication
■ Infant—cooing, babbling, laughing appropriately, repeats sounds,
makes gestures, by 12–15 mo has 3–5 words, receptive language
greater than expressive language
■ Toddler—puts together simple 2- and 3-word sentences, vocabulary
quickly expanding, should have at least 50 words by age 2 yr
■ Preschooler—points to objects and answers simple questions about
a story, uses and understands “W” questions (who, what, where,
when, why)
■ School-age child—appropriate receptive/expressive language for
age; develops reading, spelling, writing skills; appreciates language
implications of jokes, riddles, etc.; consult recent educational
assessment
■ Adolescent—development of sophisticated reading, spelling, writing
skills; consult recent educational assessment
■ Assessment of ability to make needs known based on age
EXAM/EVAL
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EXAM/EVAL
■ Learning style and learning preferences of child and family (educational

needs, learning barriers)
■ Auditory
■ Visual
■ Tactile
■ Kinesthetic
■ Vision
■ Infant—visual tracking to and past midline, symmetry with eye
movement, corneal light reflex
■ Toddler—by age 3 all children should have had a formal vision
screening, consult parent as to results; check visual tracking of both
eyes and with each eye covered; use Lea chart (uses shapes for
apple, house, circle, square) for visual acuity
■ Preschooler—use Allen chart (tumbling “E” chart) for visual acuity;
check visual tracking and convergence
■ School-age child—when a child knows his or her letters, HOTV sys-
tem or Snellen eye chart can be used
■ Adolescent—Snellen eye chart
HOTV can be accessed for free at: http://www.preventblindness.org/eye_tests/

Adult_distance_test.html
■ Hearing
■ Infant—awakens or startles at loud noises; by 3 mo turns eyes and
smiles when spoken to; by 6 mo turns head to sound, responds to
name, and starts to babble; many states require or offer infant
screening at the time of birth
■ Toddler—by 12 mo begins to understand sounds/words, begins to
imitate sounds; by 2 yr points to pictures/body parts when named,
listens to songs, developing speech
■ Preschooler—should be able to ask and answer questions, under-
stand speech from unfamiliar voices, show interest and interaction
with simple stories
■ School-age child and adolescent—able to watch TV at normal vol-
ume; caution if note articulation problems, needs to watch others
to get clues about verbal commands, responds inappropriately to
verbal requests, needs or asks for commands to be repeated, may
appear inattentive
16
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17
■ Contextual factors—personal qualities:
■ Age
■ Gender
■ Cultural heritage
■ Socioeconomic status
Contextual factors—environmental qualities (including personal and envi-

ronmental factors):
■ Use of adaptive devices, modifications to environments or routines
■ Social support systems and relationships
■ Other services or agencies providing support
■ Potential barriers in various environments significant to child and
family/caregivers:
■ Stairs, ramps, doors (width and direction of operation)
■ Hallways (width, turning radius)
■ Key rooms: bathroom, bedroom, living areas
■ Presence of carpets, types of thresholds
■ Safety/childproofing (heating units, door locks, outlets)
■ Environmental controls
Examination—Cardiovascular-Pulmonary System
Cardiovascular
■ Observation/complaints
■ General color (cyanosis, pallor, etc.)
■ Symmetry of chest, chest deformities (e.g., pectus excavatum or
“funnel chest,” pectus carinatum or “pigeon chest”)
■ In infants: feeding intolerance, failure to thrive, respiratory
symptoms
■ In older children: chest pain (particularly after activity), syncope,
exercise intolerance
■ Heart rate
■ Rate
■ Rhythm
■ Amplitude
EXAM/EVAL
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EXAM/EVAL
■ Capillary refill—measure the time in seconds it takes for normal color-

ation to reappear after release of pressure on nail bed or soft tissue;
assess for possible dehydration and reduced perfusion (capillary refill
of >2 sec)
■ Peripheral pulses/circulation—measure for at least 30 seconds; some
pulses (radial, dorsal pedal, posterior tibial) are difficult to palpate in
infants and young children and may be mistaken for weak or absent
pulses; weak or absent femoral pulse may indicate coarctation of the
aorta
■ Rate
■ Regularity
■ Symmetry
■ Amplitude
• 4+ = bounding
• 3+ = increased
• 2+ = normal
• 1+ = weak, thready
• 0 = absent
Palpation of Peripheral Pulses
Brachial
Femoral
Popliteal
(behind knee)
Dorsalis pedis
18
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19
Radial pulse
Carotid pulse
Note: In infants and very young children, the brachial pulse is preferred
for the assessment of HR, rather than palpation of the carotid pulse.
■ Auscultation of heart sounds (with stethoscope)
■ General principles: Use appropriate size for child’s age/size; start
at base of heart (top) and work to the apex; bell best for low- to
medium-pitched sounds/murmurs (3/4” for infants and 1” for children);
diaphragm is best for higher-pitched murmurs
■ S1 (first heart sound): Found over lower left border of sternum;
indicates closure of mitral and tricuspid values; should be one
sound; absence of S1 can indicate ventral septal defects, atrioven-
tricular valve regurgitation, patent ductus arteriosus; two sounds or
clicks can indicate asynchronous closure of the valves; listen in
upper right sternal area for aortic valve, upper left sternal area for
pulmonic valve, lower left sternal area for ventriculoseptal defects,
and apical area for aortic or mitral valve
■ S2 (second heart sound): Found over the upper left border of ster-
num; indicates closure of aortic and pulmonic valves; during inspi-
ration the sound should split (A2 [aortic] and P2 [pulmonic]); only
one sound could indicate pulmonary hypertension or involvement
of the semilunar valves
■ Additional sounds (S3 and S4): These sounds are best assessed
using the diaphragm of the stethoscope and with the child lying on
the left side; note the location and timing during the S1-S2 cycle; S3
can be a normal finding
EXAM/EVAL
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EXAM/EVAL
■ Systolic murmurs: Sounds that occur between S1 and S2 can

indicate turbulent blood flow caused by a ventricular septal defect,
valve regurgitation (mitral or tricuspid), or patent ductus arteriosus;
many systolic murmurs are “functional” or benign; systolic mur-
murs are timed as early, middle, or late
■ Diastolic murmurs: Sounds that occur after S2 can indicate valve
regurgitation (aortic or pulmonic) or stenosis (mitral or tricuspid);
also timed as early, middle, or late; most, if not all, diastolic mur-
murs are pathological and require referral
■ Venous hum: Sound heard consistently while child is sitting, caused
by the venous blood flow from head and neck to thorax; very com-
mon in functional murmurs; disappears with light pressure over
jugular vein, head turning, or change of position
Scale for Grading Cardiac Murmurs*

I Lowest intensity, often not heard even by experts (clearly
softer than heart sounds)
II Low intensity, typically heard by most (about equal in intensity
as heart sounds)
III Medium intensity, easy to hear, but no palpable thrill (clearly
louder than heart sounds)
IV Medium intensity with palpable thrill
V Loud intensity, palpable thrill, heard even with stethoscope at
level of diaphragm
VI Loudest intensity, palpable thrill, heard even with stethoscope
raised above chest
*All murmurs greater than grade III are pathological.
Source: Adapted from Keren, R., Tereschuk, M., Luan, X. Evaluation of a novel method for grad-
ing heart murmur intensity. Arch Pediatrc Adolesc Med. 2005;159:329–334.
20
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21
Auscultation of Heart Sounds
Pulmonic area
(2nd intercostal space on L)
Erb’s point
(3rd intercostal space on L)
Tricuspid area
Aortic area (4th intercostal space–may
(2nd intercostal be heard on R or L sides in
space on R) young children)
Apex/mitral area
(5th intercostal space on L
at midclavicular line)
Pulmonary—Ventilation and Respiration/Gas Exchange

■ Observation
■ Posture—asymmetries, chest deformities (e.g., pectus excavatum or
“funnel chest,” pectus carinatum or “pigeon chest”), position/angle
of ribs
■ Unusual pulsations
■ Finger clubbing
■ Palpation
■ Tactile fremitus
■ Chest excursion
■ Rib mobility
■ Percussion
■ Place second finger on chest wall location, use index and second fin-
ger of opposite hand to strike with DIP joint area of palpating hand
■ Compare right and left sides, all lobes
EXAM/EVAL
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EXAM/EVAL
■ Normal air-filled lung should sound low-pitched and drumlike

■ Louder/hollow sound indicates air in the pleura or hyperinflation
■ Duller sound indicates fluid in the pleura or consolidation
■ Respiratory rate
■ Rate
■ Rhythm
■ Depth
■ Auscultation of lung/breath sounds (with stethoscope)
■ General principles: use appropriate size for child’s age/size; use the
diaphragm to listen during inspiration and expiration, for at least
two breaths bilaterally; start with the back, move top to
bottom, then move to front of chest
Breath Sound Description

Bronchial Moderate intensity and pitch with equal inspiratory
and expiratory phases, louder than normal
Cavernous Deep hollow sounds (similar to blowing over a bottle)
Course crackles Discontinuous (starts/stops); fine, medium, or coarse
(inspiratory and expiratory); alveoli opening (fine),
fluid in bronchioles (medium), fluid in large airways
(coarse)
Fine crackles Popping sounds heard at the end of inspiration
Pleural rub Low-pitched coarse rubbing sound, at end of inspira-
tion and beginning of expiration
Rales Clicking, bubbling, rattling sounds
Rhonchi Coarse, wet, low-pitched, continuous, from large
amounts of secretions; can resemble snoring (may
clear with coughing)
Rub Grating or creaking sound (similar to leather rubbing)
Vesicular Low-pitched/soft with inspiration longer than expiration
Wheezes Continuous musical sound (inspiratory and expiratory),
air flowing via narrowed airway lumen; monophonic or
polyphonic (multiple pitches)
22
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23
Auscultation of Lung/Breath Sounds
1 2
2 1 4 3
1
3 4 5 6
7
6 5 3 8 7
2
9 10
Sputum
Sputum induction is safe in children >6 yr (most commonly done in chil-
dren with asthma and cystic fibrosis); productive cough should be
assessed for:
■ Amount (scant, moderate, copious)
■ Color
Clear Normal
White Bronchitis, cystic fibrosis
White and frothy Pulmonary edema
Yellow–pale green Infection
Rusty Pneumonia
■ Consistency/character
Watery Asthma acute bronchitis
Viscous Bronchiectasis, respiratory tract infection
Semiliquid Normal
Frothy Pulmonary edema, CHF
EXAM/EVAL
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EXAM/EVAL
■ Odor
No odor Normal
Foul-smelling Anaerobic infection, lung abscess, CF, bronchiectasis
■ Presence of blood
Hemoptysis Pneumonia, acute bronchitis, lung CA, TB
■ Laboratory testing can be done for presence of red and white blood
cells
Aerobic Capacity/Endurance/Exertion
Examples of simple clinical measures:
■ 6-Minute Walk Test (6MWT)—for children >5 yr; can be done with and
without assistive device; measure distance covered in 6 min (rests
are allowed); can be shorted to a 2-min walk test for children who are
severely ill; norm values for 4–11 yr (see Lammers, A.E., et al, 2007),
7–16 yr (see Li, A.M., et al, 2007); commonly used in children with
respiratory dysfunction (e.g., CF), but has been shown reliable in
ambulatory children 11–17 yr with CP (Maher et al., 2008)
■ 3-Minute Step Test—up and down a 15-cm single step for 3 min at a
rate of 30 steps/min (externally pace with metronome or music),
measure HR for at least 15 sec and within 5 sec of stopping; may be
used post ex HR to predict O2 consumption (Balfour-Lynn et al., 1998)
■ Physiologic Cost Index (PCI)—can be used to measure the “cost”
of walking; walk at preferred walking speed (typically 50 m); measure
HR at rest, when walking, and walking speed; for nondisabled children
3–12 yr typical PCI (with shoes) is 0.40 beats/m (Butler et al.,1984);
Raja et al. (2007) found PCI of 0.1 in typically developing children, PCI
6 times greater in children with CP (most notably in children with
crouch gait)
PCI = (HR in beats/min walking - HR rest)/speed in m/min
■ Fifteen Count Breathlessness Score—take in deep breath then count
out loud to 15, score is the number of breaths taken to get to 15;
objective measure that is recommended in conjunction with a subjec-
tive measure (e.g., Borg or VAS) (Ammani Prasad et al., 2000)
24
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25
■ Modified Borg Rate of Perceived Exertion (RPE) Scale—self-rating of
effort during activity, may be most appropriate for older children
0 Nothing at all
0.5 Very, very light
1 Very light
2 Light
3 Moderate
4 Somewhat heavy
5 Heavy
7 Very heavy
10 Very, very heavy
* Maximal
Source: Adapted from Borg, G.A.V.: Psychophysical bases of
perceived exertion. Med Sci Sports Exerc. 1982; 14:377–381.
EXAM/EVAL
Page 26
■ Dalhousie Dyspnea Scales—three pictorial scales that measure the

extent of perceived throat closing, chest tightening, and physical
4:39 PM
3/11/10
26
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EXAM/EVAL
effort
Source: McGrath, P.J., Pianosi, P.T., Unruh, A.M., and Buckley, C.P.: Dalhousie dyspnea scales: Construct and content
validity of pictorial scales for measuring dyspnea. BMC Pediatrics. 2005; 5:33, with permission.
■ Children’s Effort Rating Table (Pictorial CERT)—a measure of exercise intensity that uses pictorial
Page 27
and word descriptors

4:39 PM
3/11/10
27
1815_Tab02_007-098.qxd
EXAM/EVAL
Source: Daley, A.J., Copeland, R.J., Wright, N.P., and Wales, J.K.H.: Protocol for Sheffield obesity trial (SHOT): A randomised clinical con-
trolled trial of exercise therapy and mental health outcomes in obese adolescents. BMC Public Health. 2005; 5:113, with permission.
1815_Tab02_007-098.qxd 3/11/10 4:39 PM Page 28
EXAM/EVAL
Examination—Neuromuscular System
Arousal, Attention, and Cognition
■ Orientation (time, date, person, place, etc.)
■ Level of consciousness
Pediatric Coma Scale

Eye Opening Score
Spontaneously 4
To verbal stimuli 3
To pain 2
Never 1
Best Verbal/Nonverbal Response Score
Nonverbal child Verbal child
Smiles, orients to sound, Oriented and converses 5
follows objects, interacts ‫اﻟﺤﻴﺮة واﻟﻤﺤﺎدﺛﺎت‬
Consolable when crying, ‫ ﻋﺰاء ﻋﻨﺪ اﻟﺒﻜﺎء‬Disoriented and converses 4
interacts inappropriately
‫ﻋﺰاء و ﻳﺸﺘﻜﻲ‬
Inconsistently consolable and Inappropriate words 3
moans, makes vocal sounds ‫ﻏﻴﺮ ﻣﻔﻬﻮم‬
Inconsolable, irritable, Incomprehensible sounds 2
restless, cries
No response No response 1
Best Motor Response Score
Obey commands‫ِأﻃﻊ اﻷواﻣﺮ‬ 6
Localizes pain 5
Flexion withdrawal 4
Abnormal flexion
(decorticate rigidity) 3
Extension (decerebrate 2
rigidity)
No response 1
Continued
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29
Pediatric Coma Scale—cont’d
Total score for all three sections:
• 15 = best prognosis; 3 = worse prognosis
• 7+ = good chance of recovery
• 3–5 = potentially fatal (likelihood increases with fixed pupils, absent
oculovestibular response, or increased intracranial pressure
Source: Simpson, D.A., Cockington, R.A., Hanieh, A., Raftos, J., and Reilly, P.L.: Head injuries in
infants and young children: The value of the Paediatric Coma Scale. Review of literature and
report on a study. Child’s Nerv Syst. 1991; 7:183–190.
Cranial and Peripheral Nerve Integrity

Cranial Nerve Major Functions
I Olfactory Smell
II Optic Vision
III Oculomotor Eyelid & eye movement, pupil size
IV Trochlear Innervates superior oblique, turns eye downward
and laterally
V Trigeminal Chewing, face & mouth touch & pain
VI Abducens Rotates eyes laterally
VII Facial Controls most facial expressions, secretion of
tears & saliva taste
VIII Vestibulocochlear Hearing, equilibrium sensation
(auditory)
IX Glossopharyngeal Taste, senses carotid blood pressure
X Vagus Senses aortic blood pressure, slows heart rate,
stimulates digestive organs, taste
XI Spinal Accessory Controls trapezius & sternocleidomastoid,
controls swallowing movements
XII Hypoglossal Controls tongue movements
EXAM/EVAL
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EXAM/EVAL
Neuromotor Development and Sensory Integration
Primitive Reflexes—Appearance and Timing

Age in Months
0 0.5 1 2 3 4 5 6
Suck/swallow
Rooting
Galant
Palmar grasp
Plantar grasp
Moro
Stepping
Color Code:
Typical timing
Diminishing response
Attitudinal Reflexes—Appearance and Timing

Age (mo)
2 4 6 8 10 12
ATNR
TLR
STNR
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31
Righting Reactions—Appearance and Timing
Age (mo/yr)
2–3 mo 4–5 mo 1 yr 5 yr Life
Optical
Labyrinthine
Body on head
Landau
Neck on body
Body on body
Protective Extension Reactions—Appearance

and Timing
Age (mo)
4–5 6–7 8–10 12–15 Life
‫اﻟﻤﻈﻠﺔ‬
Parachute LE
Parachute UE
Sitting to front
Sitting to sides
Sitting to back
Standing
Postural Fixation/Tilting Reactions—Appearance

and Timing
Age (mo)
5–6 7–8 9–10 12–15 Life
Prone
Supine
Sitting
Quadruped
Standing
EXAM/EVAL
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EXAM/EVAL
Testing of Selected Reflexes

Name/Typical Position Illustration Stimulus/Response
Rooting/sucking— • S—stroke perioral
any position area when hungry
• R—turns head and

opens mouth
toward stimulus
Palmar grasp— • S—pressure placed

any position in the palm of
hand
• R—flexion of the
fingers
Plantar grasp— • S—pressure placed

any position on sole of foot (ball
of foot, at the level
near the metatarsal
heads)
• R—flexion of the
toes
Continued
32
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33
Testing of Selected Reflexes—cont’d
Galant—prone • S—stroke skin over
paravertebral area
• R—curvature of
trunk on side that is
stroked
Implications: Persistence of primitive reflexes (such as those listed on

this page and the next) is thought to be a possible sign of CNS dysfunc-
tion and may help to identify early signs of several conditions, including
cerebral palsy, autism, Asperger’s syndrome, and speech dysfunction.
Persistence of these reflexes may also interfere with development of
postural control, mobility, and achievement of motor milestones.
Moro— supported • S—quick neck
sitting extension (head
drops back) about
30 degrees
• R—arms extend
and abduct, fingers
splay; may be fol-
lowed with arm flex-
ion and adduction
Continued
EXAM/EVAL
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EXAM/EVAL

Asymmetric tonic • S—turning of the
neck (ATNR) head
—supine
• R—extension of the
arm on the side the
face is turned,
flexion of the arm
on the side of the
skull, similar but
less pronounced
response in the legs
Symmetric tonic neck • S—flexion or

(STNR)—prone/ extension of the
quadruped head
• R—arms flex with

head flexion, and
hips move into
extension; arms
extend with head
extension, and hips
move into flexion
Continued
34
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35
Stepping—supported • S—support in
standing standing, feet in
contact with surface
and shift weight
forward
• R—rhythmic, alter-
nating steplike
movements (mostly
a function of hip
flexion)
Testing of Selected Postural Responses

Name How to Test Implications
Righting (head Observe righting of head Lack of develop-
and trunk) and trunk to the horizon ment of righting
while tilting (holding the responses may
child in space or on a mov- impact the develop-
able surface) to the sides, ment of head and
forward, or backward in trunk control for
any position; to test for sitting, standing,
labyrinthine response only, mobility, etc.
occlude vision to diminish
optical righting response
Protective "Parachute" methods of test- Lack of develop-
extension ing require that the child be ment of protective
moved quickly toward a sur- extension responses
face (head down for UEs, may result in
feet down for LEs); positive decreased ability to
response occurs when child maintain and move
extends extremities toward in and out of func-
the surface; also can be test- tional positions or
ed in functional positions prevent injury
Continued
EXAM/EVAL
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EXAM/EVAL
Testing of Selected Postural Responses—cont’d

Name How to Test Implications
‫ﻣﺪﻳﻦ ل‬
Protective (sitting, quadruped, stand- owing to loss of
extension ing) and in all directions balance; may con-
(cont’d) (front, side, rear) by having tribute to fear of
the child reach far enough movement
outside of the base of sup-
port (internal perturbation),
or quickly moving the child
so that the center of gravity
‫ﻳﺘﺠﺎوز‬
exceeds the limits of the
base of support (external
perturbation)
Equilibrium ‫ﻣﺘﻄﻮر‬ Sophisticated righting Lack of develop-
responses involving the ment of equilibrium
entire body, testing can responses may
occur via a movable surface result in decreased
(external perturbation) or by balance and control
challenging balance (inter- in static and
nal perturbation); positive dynamic postures
responses involve righting
head and body toward the
direction of the tilt (or to
move the center of gravity
over the base of support)
and may involve movement
in the transverse plane
(trunk rotation) and exten-
sion of extremities
Reflex Integrity
Deep Tendon Reflexes
Normally hyperreflexive in neonates, normal response should be same as
for adults by age 6 yr, may need to use distraction maneuvers with young
children
36
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37
Scale
0 = No reflex response
1 = Minimal response
2 = Moderate response
3 = Brisk, strong response
4 = Clonus
Muscle (Root) and Nerve Where/How to Test
Biceps
(C5–C6)
Musculocutaneous
Brachioradialis
(C5–C6)
Radial
Continued
EXAM/EVAL
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EXAM/EVAL

Triceps
(C7)
radial
Quadriceps
(L3–L4)
Femoral
Continued
38
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39
Gastrocnemius
(S1)
Sciatic/tibial
Note: Babinski reflex (upgoing toes with plantar stimulation, from heel
up and over lateral border of sole of foot) present in a child may indi-
cate CNS dysfunction, but can be normal in newborns and young
infants.
EXAM/EVAL
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EXAM/EVAL
Sensory Integrity
Dermatomal Distribution—cutaneous areas of peripheral nerve
innervation
C2
T2
C3 T3
C4 T4
T5
C5 T6
T7
T8
T9
C6 T10
T1 T11
T12
C7 C8 L1
S2 C2
S3
L2
C3
C4
L3 C5
C6
L5 T1
L4 T2
C7
T3
T4
S1
T5
T6
C8 T7
T8
T9
T10
Co. T11
S5 T12
S2
S4 L1
S3 L2
L1 L2 L3
L4
L3
L5
S1
L5
40
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41
Types of Sensory Testing
■ Superficial
■ Sharp/dull discrimination
■ Temperature
■ Light touch
■ Pressure
■ Deep (proprioceptive)
■ Movement sense
■ Position sense
■ Vibration
■ Combined (cortical)
■ Tactile localization
■ Two-point discrimination
■ Bilateral simultaneous stimulation
■ Stereognosis
■ Barognosis
■ Graphesthesia
■ Recognition of texture
Terminology—Common Sensory Deficits

Analgesia Complete loss of pain sensibility
Anesthesia Loss of sensation
Astereognosis Inability to recognize the form and shape of objects
(tactile agnosia)
Causalgia Painful burning sensations
Hypalgesia Decreased sensitivity to pain
Hyperalgesia Increased sensitivity to pain
Hyperesthesia Increased sensitivity to sensory stimuli
Hypoesthesia Decreased sensitivity to sensory stimuli
Paresthesia Abnormal sensation
EXAM/EVAL
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EXAM/EVAL
Motor Function
Myotomal Distribution
C1 Cervical nerves
C2 Head and neck
C3 Diaphragm
C4 Deltoids, Biceps
C5 Wrist extenders
C6 Triceps
C7 Hand
C8 Thoracic nerves
T1
T2 Chest muscles
T3
T4
T5
T6
T7
T8
T9 Abdominal muscles
T10
T11
T12
Lumbar nerves
L1
L2 Leg muscles
L3
L4
L5 Sacral nerves
S1 Bowel, Bladder
S2
S3 Sexual function
S4
S5
Types of Motor Testing

■ Muscle activation/force production/power
■ Stroking over muscle belly
■ Manual muscle test (see Musculoskeletal section)
■ Dynamometry (handheld) (‫دﻳﻨﺎﻣﻮﻣﺘﺮ )ﻣﺤﻤﻮل‬
■ One repetition maximum
■ Muscle timing and sequencing
■ Electromyography (EMG)
■ Muscle endurance
■ Dynamometry (isokinetic)
■ Functional performance (see Musculoskeletal section)
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43
Terminology—Common Motor Control
Deficits (CNS)
Akinesia Unable to initiate movement Basal ganglia
Ataxia Poor or lack of coordination Cerebellum
of movements
Athetosis Slow, involuntary, writhing,‫ﻳﺘﻠﻮى‬ Basal ganglia
‫ﺛﻌﺒﺎن‬
twisting, snakelike movement
Bradykinesia Slow movement Basal ganglia
Chorea Involuntary, rapid, irregular, Basal ganglia
jerky movement
Choreoathetosis Combination of chorea and Basal ganglia
athetosis
Dysarthria Disorder of speech Cerebellum
Dysdiadochokinesia Impaired ability to alternate Cerebellum
movements rapidly
Dysmetria Unable to judge distance or Cerebellum
range of a movement (can be
hypermetria or hypometria)
Hypertonia Abnormal increase in Cerebral cortex;
muscle tightness/stiffness spinal cord
Hypotonia Decreased resistance to Cerebellum
passive movement
Nystagmus Rhythmic, oscillatory Cerebellum
movement of eye; occurs
normally after body rotation
Paralysis Complete loss of muscle Cerebral cortex;
function spinal cord
Paresis Partial loss of muscle Cerebral cortex;
function spinal cord
Spasticity Velocity-dependent increase Cerebral cortex;
in resistance to passive spinal cord
movement
Rigidity Increased muscle tone and Basal ganglia
resistance to passive move-
ment throughout ROM
EXAM/EVAL
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EXAM/EVAL
Measurements of Muscle Tone/Spasticity
Score Spasm Frequency Scale

0 No spasms
1 Mild spasms induced only by stimulation
2 Irregular strong spasms occurring <1•/hr
3 Spasms >1/hr
4 Spasms >10/hr
Source: Penn, R.D., Savoy, S.M., Corcos, D., Latash, M., Gottlieb, G., Parke, B., and Kroin, J.S.:
Intrathecal baclofen for severe spinal spasticity. N Engl J Med. 1989; 320:1517–1521
Score Modified Ashworth Scale

0 No increase in muscle tone
1 Slight increase in muscle tone, manifested by a catch and
release or by minimal resistance at the end of ROM when the
affected part is moved in flexion or extension
1+ Slight increase in muscle tone, manifested by a catch, followed
by minimal resistance throughout the remainder (less than
half) of ROM
2 More marked increase in muscle tone through most of ROM,
but affected part easily moved
3 Considerable increase in muscle tone, passive movement difficult
4 Affected part rigid in flexion or extension
Source: Bohannon, R.W., and Smith, M.B.: Interrater reliability of a modified Ashworth scale of
muscle spasticity. Phys Ther. 1987; 67:207–208.
Score Modified Tardieu Scale

Quality of Muscle Reaction
0 No resistance throughout course of passive movement
1 Slight resistance through course of passive movement; no
clear “catch” at a precise angle
2 Clear “catch” at a precise angle, interrupting the passive
movement, followed by a release
3 Fatigable clonus (<10 sec when maintaining pressure) appear-
ing at a precise angle
Continued
44
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45
Score Modified Tardieu Scale
Quality of Muscle Reaction
4 Unfatigable clonus (>10 sec when maintaining pressure) at a
precise angle
5 Joint immovable
Joint Angles
R1 Angle of muscle reaction; “catch” of muscle during quick stretch
(velocity = V3)
R2 Angle of full passive ROM (velocity = V1)
Velocity
V1 As slow as possible (slower than limb drop under gravity)
V2 Speed of limb drop under gravity
V3 As fast as possible (faster than limb drop under gravity)
Source: Yam, W.K.L., and Leung, M.S.M.: Interrater reliability of modified Ashworth scale and modi-
fied Tardieu scale in children with spastic cerebral palsy. J Child Neurol. 2006; 21:1031–1035
EXAM/EVAL
Page 46
Motor Development/Motor Milestones

4:39 PM
Key Motor Milestones by Age and Domain of Development—First Year

‫اﻟﻤﺤﺮك اﻟﺸﺪ اﻟﻤﺴﺒﻖ‬
/
Age Gross Motor Fine Motor/Prehension Oral Motor
0–1 mo Lifts, rotates head; kicks Opens and closes hand; Rooting and suckle pattern for
symmetrically may attempt reach gaining nourishment
3/11/10
2–3 mo Decreased head lag with Reaches and grasps; Hands to mouth; control of
pull to sit; begins prop on poor control of suck, swallow, breathe with
elbows (prone) release breastfeeding or bottle feeding
46
4–5 mo Hand to feet play in supine; Palmar grasp; can First textures (if able to hold
attempts roll to side; may sit hold a toy with two head erect in semireclined sit-
with support; may push up hands ting position); may initially
1815_Tab02_007-098.qxd
on extended elbows in prone show tongue thrust

6–7 mo Sits without support; may Rakes for small Holds bottle for drinking; may
achieve hands and knees; objects; can hold start finger feeding (easy dis-
rolls supine to/from prone; object in palm using solving cookie or cracker), ver-
attempts belly crawling fingers and thumb in tical chewing
EXAM/EVAL
a radial palmar grasp

Continued
Page 47
4:39 PM
Key Motor Milestones by Age and Domain

of Development—First Year—cont’d
3/11/10
Age Gross Motor Fine Motor/Prehension Oral Motor

8–9 mo Transitions in/out of posi- Developing controlled Uses top lip to clear food from
tions; may pull to stand; release of objects; uses spoon; uses tongue to lateral-
47
crawls; attempts creeping radial digital grasp ize food; uses sippy cup
10–11 mo Cruises on furniture; may Developing inferior pin- Chews soft to firm foods, keeps
walk with hands held; creeps cer grasp (thumb and most in mouth, swallows with-
1815_Tab02_007-098.qxd
rapidly; stands alone briefly middle of index finger) out choking

12 mo Rises to stand through Developing fine pincer Scoops with a spoon, finger
hands and knees; first inde- grasp (tips of thumb feeds well; chews and swal-
pendent steps; lowers self and index finger) lows firmer foods without
from standing with control choking, rotatory chewing
EXAM/EVAL
World Health Organization—Windows of Achievement of Six Major
Page 48
Motor Milestones
Walking alone
4:39 PM
Standing alone
Motor milestone
Walking with assistance

3/11/10
48
Hands-&-knees crawling
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Standing with assistance

Sitting without support
EXAM/EVAL
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Age in months
Source: WHO Multicentre Growth Reference Study Group: WHO Motor Development Study: Windows
of achievement for six gross motor development milestones. Acta Paediatr Suppl. 2006; 450:86–95,
with permission. Note: For other helpful data about these motor milestones, see: http://www.who.int/
childgrowth/standards/motor_milestones/en/index.html
Page 49
Key Motor Milestones by Age and Domain of Development—Toddler

and Early Elementary School Age
4:39 PM
Age Gross Motor Fine Motor/Prehension

18 mo Creeps up and down steps; begins Begins to scribble; uses palmar-supinate grip on
to run stiffly utensil; plays with shape sorter
2 yr Uses railing on steps; jumps off Tries vertical and horizontal strokes; uses digital-
small step; kicks a ball pronate grip on utensil; able to do simple puzzles
3/11/10
3 yr Rides a trike; “true” run; alternates Able to copy a circle; stacks 10 blocks; undresses
feet ascending stairs; jumps over self; strings large beads
small object
49
4 yr Alternates feet descending stairs; Able to trace a diamond; copies a cross; uses
throws ball overhand with some static tripod grip of utensil; cuts straight line with
trunk rotation; catches ball by scissors; brushes teeth
1815_Tab02_007-098.qxd
trapping; gallops
5 yr Hops 8–10 times on one foot; can Able to copy a triangle; uses dynamic tripod grip
hit target with ball from 10 ft; on utensil; writes letters and numbers; buttons
balances one foot 10 sec; skips; small buttons; prepares simple breakfast; catches
walks on balance beam balls well; manages most of self-care
EXAM/EVAL
6–8 yr Plays hopscotch; can use skates; Able to manage a zipper; may tie shoes; copies a
rides a two-wheeled bicycle; diamond; uses scissors to cut shapes; greater
jumps rope; can hit a ball with a control and refinement with writing; manages all
bat; jumps down several steps self-care; prints well, may write in cursive
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EXAM/EVAL
Motor Learning—Definition of Concepts for Assessment

■ Distinguish learning from performance: Learning is exhibited in a rel-
atively permanent change in behavior, one that can be repeated over
time and preferably in other contexts
■ Learning style: Determine the child and family/caregivers’ preferred
method of learning new information; when applied to motor learning,
consider the child’s success with verbal instructions/prompts, physical
guidance, visual demonstration, peer modeling, etc.
■ Transfer of learning: Exhibited in the learning of a new task gained
through practice or experience with a different or related task
■ Generalizability: Exhibited in the learning of a task in one context that
is also observed to occur or be adapted for success in other,
dissimilar contexts or environments
■ Retention: Exhibited when an acquired skill or movement that has not
been practiced or reinforced for a period of time is evaluated for con-
tinued presence of the skill or movement
■ Feedback: Refers to the frequency (the percentage of trials for which
feedback is given, e.g., 100%, 50%), and the type of feedback, provid-
ing information on either the performance of a movement or compo-
nents of a movement (knowledge of performance, or KP) or informa-
tion on the outcome or success of the movement (knowledge of
results or KR)
■ Practice: Evaluate the child’s ability to learn new tasks through use of
practice schedules; massed or blocked practice is exhibited when a
task is practiced repeatedly in the same environment and with little
modification (may be most helpful when first performing a task or
movement); random or variable practice is exhibited when different
components or different but related tasks are practiced within a ses-
sion (thought to be better for learning)
Balance
■ Single limb stance
■ By age 4, children should be able to balance on one foot with eyes
open for at least 5 sec.
■ Children 4–9 yr may be able to balance in single limb stance with
eyes closed for only 6–7 sec (Atwater et al., 1990).
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51
Cutoff Points (Time in Seconds) for “Balance on One Foot” (eyes open)
item of the Stay in Step: A Gross Motor Screening Test for Children Aged
5 to 7 Years.
Age Low Medium High

5 yr (girls) 10–17 sec 18–45 sec 46–63 sec
5 yr (boys) 9–17 sec 18–49 sec 50–72 sec
6 yr (girls) 17–29 sec 30–79 sec 80 sec
6 yr (boys) 15–22 sec 23–79 sec 80 sec
7 yr (girls) 31–56 sec 57–79 sec 80 sec
7 yr (boys) 35–46 sec 47–79 sec 80 sec
Available from: http://www.sseh.uwa.edu.au/about/services/unigym/movement_assessment/ norms
■ Functional Reach Test (FRT)

■ Modified from the original test developed for adults
■ Performance varies by age, height, and size of base of support
■ Description: a ruler is affixed to the wall at the level of the child’s
acromion, child raises arm parallel to floor, feet remain in one place
while child reaches forward with fisted hand as far as possible with-
out falling, measure distance from starting to ending position
■ Bartlett and Birmingham (2003) modified FRT to include side
reaching
Typical Reach Distance (cm) by Age

Age Mean (95% CI)
3 yr 11.4 (10.7–12.1)
4 yr 13.6 (12.7–14.5)
5 yr 15.7 (13.8–17.7)
5–6 yr 21.17 (16.70–24.91)
7–8 yr 24.21 (20.56–27.96)
Continued
EXAM/EVAL
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EXAM/EVAL
Typical Reach Distance (cm) by Age—cont’d

Age Mean (95% CI)
9–10 yr 27.97 (25.56–31.64)
11–12 yr 32.79 (29.68–36.18)
13–15 yr 32.30 (29.58–36.08)
Source: Adapted from Norris, R.A., Wilder, E., and Norton, J.: The functional reach test in 3- to
5-year-old children without disabilities. Pediatr Phys Ther. 2008; 20:47–52; and Donohoe, B.,
Turner, D., and Worrell, T.: The use of functional reach as a measurement of balance in boys
and girls ages 5 to 15 years. Pediatr Phys Ther. 1994; 6:189–193.
■ Timed Up and Go (TUG)

■ Modified from the original test developed for adults
■ Description: a 3-m walkway is mapped on the floor; child starts
seated in an appropriate height chair; child is instructed to stand,
walk to 3-m mark, turn around, walk back, and sit in chair; record
from the “go” cue to when the child is fully seated with both feet
on the floor
■ Williams et al. (2005) found a mean TUG score of 6.7 sec (S.D. 1.2)
in children 3–5 yr and a mean score of 5.1 sec (S.D. 0.8) in children
6–9 yr.
■ Timed Up and Down Stairs (TUDS)
■ Description: child starts 30 cm from the bottom of a 14-step flight of
stairs, child is instructed to go up and down as quickly/safely as
possible via any means, record time from the “go” cue to until
both feet reach the bottom landing
■ Zaino et al. (2004) showed that children 8–14 yr complete this task
on average in 7–9 sec, and children with CP complete task on aver-
age in 14–24 sec.
■ Pediatric Balance Scale (PBS)
■ Modified from the original Berg Balance Scale for adults
■ Description: 14-item test for school-age children (for directions and
scoring see Franjoine et al., 2003).
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53
PBS Scoring Sheet 0–4 Scale Seconds
1. Sitting to standing
2. Standing to sitting
3. Transfers
4. Standing unsupported
5. Sitting unsupported
6. Standing with eyes closed
7. Standing with feet together
8. Standing with one foot in front
9. Standing on one foot
10. Turning 360 degrees
11. Turning to look behind
12. Retrieving object from floor
13. Placing alternate foot on stool
14. Reaching forward
TOTAL
■ Pediatric Clinical Test of Sensory Interaction for Balance (P-CTSIB)

■ Modified from adult version of CTSIB; evaluates use of visual,
somatosensory, and vestibular system inputs for balance
■ Description: Postural sway measured in 2.5-degree increments from
backdrop behind child during static standing in three conditions
(eyes open, eyes closed, with dome—vision stabilized); repeated in
two positions (standing on floor and standing on foam) (see
Westcott et al., 1994)
■ Romberg’s sign
■ Description: Child stands with feet together and eyes closed for
20 sec; sign is positive if sway is increased or child loses balance
or stops test
■ Children can be tested when they can stand unsupported and
follow directions; positive Romberg’s sign can indicate vestibular
dysfunction; in children it is commonly associated with spinal cord
disease.
EXAM/EVAL
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EXAM/EVAL
Gait and Locomotion

Developmental Considerations
0–9 mo
• Physiological flexion present at birth decreases with time
• High fat–to–body mass ratio
• Large head-to-body ratio
• Limb length increases rapidly
• Overall mass is increasing
• Floor mobility skills develop: rolling, creeping, moving in and out of
positions
• Supported standing
9–15 mo
• Pulling to stand and cruising around furniture
• Early walking: hips in flexion, abduction and external rotation for wide
base of support; knees in flexion to lower center of mass; ankles in ever-
sion and pronation
• Early walking: upper extremities in “high guard”
• Center of mass is high—little if any trunk rotation, lateral weight shifts
for progression
• Gait mechanics: initial contact with foot flat, very brief periods of single-
limb stance, small step lengths, high cadence, decreased dorsiflexion in
swing
• With practice: upper extremities come to “low guard,” base of support
narrows
18–24 mo
• Heel strike at initial contact evident; knee remains in some flexion in
terminal swing
• Demonstrates minimal push off
• Increased trunk rotation
• Increasing stride length
• Reciprocal arm swing begins
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55
3–4 yr
• Increased pelvic rotation
• Notable weight shifting
• Base of support is approximately equal to width of pelvis
6–7 yr
• Further narrowing of base of support
• Heel strike and push off evident
• Center of mass: horizontal translation greater than vertical translation
• Stride length increases as a function of leg length
• “Adult-like” patterns of gait are present
EXAM/EVAL
Page 56
Mean Values* for Gait Time/Distance Parameters—Normal

4:39 PM
Development With Age

*all mean values rounded up to nearest tenth of the measurement unit
Parameter 1 yr 2 yr 3 yr 4 yr 7 yr
3/11/10
Opp. toe off (% cycle) 17 17 16 14 12

Opp. foot strike (%cycle) 49 50 50 50 50
56
Single stance (% cycle) 32 34 35 36 38
Toe off (% cycle) 67 67 66 64 62
Step length (cm) 22 28 33 39 48
1815_Tab02_007-098.qxd
Stride length (cm) 43 55 67 78 97

Cycle times (sec) 0.68 0.78 0.77 0.78 0.83
Cadence (steps/min) 176 156 154 152 144
Walking velocity (cm/sec) 64 72 86 99 114
EXAM/EVAL
Walking velocity (m/min) 38.4 43.2 51.6 59.4 68.4

Source: Adapted from Sutherland, D.H., Olshen, R.A., Biden, E.N., and Wyatt, M.P.: The Development of Mature Walking.
Philadelphia: J.B. Lippincott, 1988.
Page 57
4:39 PM
Gait Cycle
3/11/10
57
1815_Tab02_007-098.qxd
Heel Toe Heel

contact off contact
0% 62% 100%
Double Single Double Single Double
support support support support support
EXAM/EVAL
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EXAM/EVAL
Common Gait Abnormalities
Upper Extremities/Trunk/Pelvis
■ Sagittal plane
■ Excessive anterior/posterior pelvic tilt
■ Excessive forward or backward lean
■ Frontal plane
■ Lateral lean
■ Contralateral drop
■ Transverse plane
■ Increased or decreased pelvic rotation
■ Decreased or absent arm swing
Hip:
■ Sagittal plane
■ Increased or decreased flexion
■ Frontal plane
■ Increased or decreased abduction/adduction
■ Trendelenburg
■ Hip hiking
■ Excessive coxa varus/valgus
■ Increased or decreased internal/external rotation
■ Circumduction
■ Excessive femoral torsion
Knee
■ Sagittal plane
■ Excessive knee flexion or hyperextension
■ Frontal plane
■ Excessive genu varus/valgus
■ Excessive tibial torsion
Foot/Ankle
■ Sagittal plane
■ Absence of heel strike at initial contact
■ Poor control in loading response/foot slap
58
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59
■ Early or absent heel off
■ Excessive plantar flexion or dorsiflexion
■ Poor foot clearance (dorsiflexion) in swing
■ Vaulting
■ Frontal plane
■ Excessive foot supination or pronation
■ In toeing or excessive out toeing
Observational Gait Analysis (OGA) Form
Scoring: 0 = normal, + = abnormal (just noticeable), ++ =

significantly abnormal (very noticeable)
Left Side Right Side
Gait Deviation HS-FF FF-HO HO-TO HS-FF FF-HO HO-TO
Knee flex.
Knee ext.
Hip flex.
Hip ext.
Genu varum
Genu valgum
Hip add.
Hip abd.
Hip IR
Hip ER
Pes varus
Pes planus
Directions: observe child’s gait from both sides and from the front, note
any deviations considering all three planes of movement, use scoring
guide to rate the level of deviation from the norm and the phase of the
cycle when it occurs
Continued
EXAM/EVAL
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EXAM/EVAL
Observational Gait Analysis (OGA) Form—cont’d
Ambulatory aids used during trial:
Orthotic or prosthetic devices used during this trial:
Comments:
HS heel strike, FF foot flat, HO heel off, TO toe off

Source: Adapted from Krebs, D.E., Edelstein, J.E., and Fishman, S.: Reliability of observational
kinematic gait analysis. Phys Ther. 1985; 65:1027–1033.
Examination—Musculoskeletal System
Anthropometrics
■ Head circumference (occipitofrontal circumference)
■ Use a nonflexible measuring device/tape in inches
■ Measure circumference around occiput and most anterior portion
of the frontal bone, above eyebrows and ears
■ Adjust measuring device to obtain the largest possible measurement
■ See CDC charts on following pages for percentiles
■ Height
■ Use a nonflexible measuring device/tape or a standing height
measurement device or reference point on a wall surface, measure-
ment is in inches
■ Infants/young children should be positioned in supine on a flat sur-
face, measure distance on that flat surface from head to bottom of
flat foot, ensure knees are extended
■ Children and adolescents should be measured in standing if possible
60
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61
■ Weight
■ Use age-appropriate scale; measure in pounds
■ Infants/young children should be weighed naked or with an empty
diaper; children and adolescents should remove shoes and heavy
clothing
■ Body mass index calculation
■ BMI = [weight/(height • height)] • 703
Interpreting BMI in Children

(http://www.CDC.gov)
BMI Percentile Range Category

<5th percentile Underweight
5th–85th percentile Healthy weight
85th–95th percentile Overweight
>95th percentile Obese
EXAM/EVAL
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EXAM/EVAL
Source: The Centers for Disease Control and Prevention

http://www.cdc.gov/nchs/data/nhanes/growthcharts/set1clinical/Cj41cs019c.pdf, accessed
July 15, 2009
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63

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EXAM/EVAL

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EXAM/EVAL
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EXAM/EVAL
Posture/Alignment
■ Common postural dysfunctions/deformities
Kyphosis
Scoliosis
Kyphosis Scoliosis
Pectus Carinatum Pectus Excavatum
Depression
Pigeon breast in chest
Pectus carinatum Pectus excavatum
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71
■ Analyze for asymmetry and lack of normal spinal curvatures in:
■ Prone
■ Supine
■ Sitting
■ Quadruped
■ Standing
■ Transitional movements
■ Screening for scoliosis
■ Forward bend test—prominence of ribs on one side
■ Leg lengths—true (ASIS to medial malleolus may indicate leg
length difference in femur, tibia, or both) and apparent (umbilicus
to medial malleolus may indicate pelvic obliquity)
■ Uneven shoulders
■ Uneven pelvis
Scoliosis Screening
Head not
centered
over body
One shoulder
higher Normal spine Rib prominence
One shoulder-
blade higher
and possibly
more prominent
Spine obviously
curved
Unequal gaps
between the arms
and the trunk
One hip more
prominent
■ Developmental changes in lower limb alignment

■ Age-related changes in position of legs
■ Intracondylar distance (increased with genu varum) and intramalle-
olar (increased with genu valgus)
EXAM/EVAL
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EXAM/EVAL
Tibial-Femoral Angle
Newborn 1.5 to 2 yrs By 2.5 yrs By 7 yrs

Moderate Neutral Peak of Adult-like position
genu varum knee position physiologic with mild genu valgus
(~15°) (0°) genu valgus (5°–6°)
(10°–12°)
■ Rotational profile (Staheli et al., 1985, Cusick & Stuberg, 1992)

■ Pelvic rotation (check alignment of pelvis in frontal plane)
■ Internal and external hip rotation in prone
■ Estimate of femoral torsion/rotation: in prone knee flexed to
90º, palpate the greater trochanter with hip rotation, measure the
amount of hip rotation when the greater trochanter is at its most
lateral position
■ Thigh-foot axis or angle in prone knee flexed to 90º (estimates
tibial torsion/rotation)
■ Transmalleolar axis (estimates tibial torsion/rotation)
■ Heel-bisector angle (estimates forefoot abduction or adduction)
■ Foot progression angle during gait (estimates in-toeing or out-toeing)
Changes in femoral anteversion and tibial torsion: means and standard

deviations in degrees by age and gender*
Femoral Anteversion Tibial Torsion

Age (yr) Boys Girls Boys and Girls
3 26.80 (19.07) 39.65 (19.61) 34.07 (6.39)
4 30.12 (18.30) 39.09 (23.91) 34.76 (6.18)
5 21.04 (17.88) 37.31 (20.61) 35.14 (5.77)
6 22.96 (20.04) 31.15 (21.44) 33.12 (6.22)
7 16.27 (15.13) 31.00 (23.32) 33.81 (6.90)
Continued
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73
Femoral Anteversion Tibial Torsion
Age (yr) Boys Girls Boys and Girls
8 12.03 (13.89) 26.69 (19.95) 34.53 (6.26)
9 13.11 (17.69) 18.14 (18.05) 36.25 (4.86)
10 9.59 (13.30) 16.75 (17.81) 36.05 (4.90)
*No statistical difference was found between right and left sides for femoral anteversion in
either boys or girls, but girls’ values were significantly greater than boys’ values; no statistical
differences were found related to right/left sides or gender for tibial torsion.
Note: measurements of femoral anteversion and tibial torsion for this study were done with the
methods described by Staheli & Engel (1972) and Ruwe, Gage, Ozonoff & DeLuca (1992).
Source: Adapted from Jacquemier, M., Glard, Y., Pomero, V., Viehweger, E., Jouve, J., and Bollini, G.:
Rotational profile of the lower limb in 1319 healthy children. Gait Posture. 2008; 28:187–193.
Joint Integrity and Mobility: Range of Motion (ROM)

■ Developmental considerations:
■ Upper extremity motions—approximate ROM values rounded to
the nearest 5º (based on data presented in Norkin, C.C., and White,
D.J.: Measurement of Joint Motion: A Guide to Goniometry.
Philadelphia: F.A. Davis, 2003.)
Shoulder:
Motion 0–2 yr 1–5 yr 6–12 yr 13–19 yr

Flexion 0–175 0–170 0–170 0–170
Extension 0–85 0–70 0–70 0–65
Abduction 0–180 0–185 0–185 0–185
Int. rotation 0–80 0–70 0–70 0–70
Ext. rotation 0–125 0–110 0–110 0–105
Elbow and Forearm:
Motion 0–2 yr 1–5 yr 6–12 yr 13–19 yr

Flexion 0–155 0–145 0–150 0–145
Extension — 0 0 0
Supination 0–95 0–80 0–80 0–75
Pronation 0–85 0–85 0–85 0–80
EXAM/EVAL
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EXAM/EVAL
Wrist:
Motion 0–2 yr 1–5 yr 6–12 yr 13–19 yr

Flexion 0–90 0–80 0–75 0–75
Extension 0–85 0–75 0–80 0–70
Radial dev. — 0–25 0–20 0–20
Ulnar dev. — 0–40 0–35 0–35
■ Lower extremity motions—approximate ROM values rounded to

the nearest 5º (based on data presented in Norkin, C.C., and White,
D.J.: Measurement of Joint Motion: A Guide to Goniometry.
Philadelphia: F.A. Davis, 2003.)
Hip:
Motion 1 mo 4–8 mo 1–5 yr 6–12 yr 13–19 yr

Flexion 0–140 0–135 0–125 0–125 0–125
Extension 10 5 0 0–10 0–10
Abduction 0–50 0–55 0–60 0–50 0–50
Adduction — — 0–30 0–30 0–25
Int. rot.0–25 0–40 0–55 0–50 0–50
Ext. rot. 0–65 0–65 0–55 0–50 0–50
Knee:
Motion 0–2 yr 1–5 yr 6–12 yr 13–19 yr

Flexion 0–155 0–140 0–150 0–145
Extension — 0–5 0 0
Ankle:
Motion 1 mo 4–8 mo 1–5 yr 6–12 yr 13–19 yr

Dorsiflexion 0–55 0–50 0–15 0–15 0–10
Plantar flexion 0–60 0–60 0–60 0–60 0–55
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75
■ Commonly used special tests for lower limb flexibility: all measure-
ments typically done passively, but can also be measured actively
■ Thomas test for hip flexor/

iliopsoas tightness: flexion
of opposite hip keeps pelvis
neutral
■ Ely’s test for rectus femoris

tightness: hand over pelvis
can detect hip flexion during
knee flexion
■ Straight leg raise test for

hamstring tightness: stabilize
pelvis, knee remains in exten-
sion, measure degree of hip
flexion available before com-
pensation (pelvic motion,
knee flexion)
EXAM/EVAL
1815_Tab02_007-098.qxd 3/11/10 4:39 PM Page 76
EXAM/EVAL
■ Popliteal angle measure-

ment for hamstring tight-
ness: start with hip in 90º
of flexion then extend knee;
opposite leg should rest on
mat in neutral hip position,
measure amount of knee
flexion, the reverse angle is
amount of motion lacking
from full extension
■ Modified Ober test for

iliotibial band tightness:
hand over pelvis to stabilize,
measure distance of medial
epicondyle to plinth
76
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77
■ Test for gastroc-soleus flexi-
bility: to isolate gastrocne-
mius over hip and knee
joint, keep knee in exten-
sion; to assess contribution
of soleus, allow knee to be
in flexion; in either test,
keep the foot in a neutral
position or a position that
favors supination
Muscle Performance (Strength, Power, and Endurance)

Grading of Muscle Strength/Force Production
Modified British Medical Research Council

Grade Description
0 Total paralysis—no movement
1 Flicker—seen or felt in muscle
2 Movement with gravity eliminated
3− Movement against gravity, not through full ROM
3 Movement against gravity, no resistance
Continued
EXAM/EVAL
1815_Tab02_007-098.qxd 3/11/10 4:39 PM Page 78
EXAM/EVAL
Modified British Medical Research Council—cont’d

Grade Description
3+ Movement against gravity, transient resistance, but collapses
abruptly
4− Movement against gravity and minimal resistance
4 Movement against gravity and moderate resistance
4+ Movement against gravity and moderate to maximal resistance
5− Barely detectable weakness
5 Normal strength
NG Not graded because of difficulties
Source: Adapted from Florence, J.M., Pandya, S., King, W.M., Robison, J.D., Baty, J.,
Schlerbecker, J., and Signore, L.C.: Intrarater reliability of manual muscle test (Medical
Research Council Scale) grades in Duchenne’s muscular dystrophy. Phys Ther. 1992;
72:115–126.
Clinical and Functional Evaluation of Strength

(Testing Muscle Groups)
Look for nontypical movement that may be compensation for muscle
weakness; all items are to be considered relative to the age appropriate-
ness of the skill
Head and Neck
■ Lifts and rotates head in supine, prone, and side lying
Trunk and Abdominals
■ Able to rise to sitting from supine without using arms
■ Able to lift head and all four extremities in prone
Upper Extremities
■ Able to push up on extended arms in prone
■ Able to lift and carry weighted objects
■ Uses arms effectively to transition from position to position
■ Uses arms in self-care, feeding, and dressing
■ Manipulates objects with hands (opens doors and jars, manipulates
keys, coins, utensils)
78
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79
Lower Extremities
■ Transfers sit to and from standing from various heights without arms
■ Transfers from floor to and from standing without using arms
■ Able to ascend and descend steps without rail
■ Able to rise up on toes repeatedly
■ Able to walk on toes and on heels across the room
■ Sustained walking or running
Examination—Integumentary System
Integumentary Integrity
■ Visual inspection of all exposed and nonexposed skin
■ Special attention areas:
■ Diaper area
■ Bony prominences of spine and extremities
■ Scalp
■ Skin folds and crevasse
■ Nails
■ Genitalia
Classification of Lesions
■ Primary: Direct result in loss of tissue continuity
■ Secondary: Occur as result of primary lesion, may occur from irritating
or bumping, from infection, or from lack of care
■ Grouped: Several lesions in one area
■ Annular: Circular or round in configuration
■ Linear: Configured in a straight line
■ Serpiginous: May be several lesions joining together, appears to be
creeping from one part to another
■ Vesicle vs. bulla: Fluid-filled lesion, the latter is larger (>1.5 cm)
■ Macule vs. patch: Colorized flat, circumscribed lesion, the latter is larger
(>1.5 cm)
■ Papule vs. nodule: Solid, elevated lesion, the latter is larger (>1.5 cm)
EXAM/EVAL
1815_Tab02_007-098.qxd 3/11/10 4:39 PM Page 80
EXAM/EVAL
■ Plaque: Flat-topped elevated lesion

■ Pustule: Raised lesion, pus-filled
■ Wheal: Transient, result of dermal edema; elevated area with variable
erythema and blanching
Describing Skin Lesions

Location & distribution Symmetrical vs. asymmetrical, sun-exposed
areas, flexures/extensors, acral (hands/feet)
Erythema Reddening of lesion with/or without redden-
ing of underlying skin
Surface features Crusting, rough, smooth, scaly, warty
Type Cyst, macule, papule, pustule, ulcer, vesicle
Color Blue, brown, pink, purple, red, white
Arrangement Single vs. multiple, discrete, unilateral,
generalized, grouped, annular, gyrate,
dermatomal, linear, serpiginous
Border and shape Well vs. poorly defined, active edge, round,
oval, irregular, pedunculated
Staging of Pressure Ulcers

■ Stage 1: Persistent redness in pigmented skin, may have blue or
purple hues in darker skin
■ Stage 2: Partial-thickness skin loss; superficial, abrasion-like, blistering
■ Stage 3: Full-thickness skin loss, necrosis of tissue into fascia, possi-
ble undermining
■ Stage 4: Full-thickness with destruction/necrosis of muscle, bone,
tendon, ligaments; may have undermining/sinus tracts
■ Eschar: Thick black necrotic tissue; presence of eschar limits accurate
staging of ulcer
80
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81
Staging Pressure Ulcers
Stage 1 Stage 3
Epidermis
Dermis
Adipose tissue
Muscle
Bone
Stage 2 Stage 4
Common Skin Lesions Seen in Children
Basal Cell Carcinoma† Blue Nevi‡
Continued
EXAM/EVAL
1815_Tab02_007-098.qxd 3/11/10 4:39 PM Page 82
EXAM/EVAL
Contact Dermatitis† Cystic Acne†
Eczema† Hand, Foot, and Mouth Disease†
Impetigo‡ Malignant Melanoma†
Continued
82
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83
Methicillin-Resistant S.
aureus (MRSA) ‡ Molluscum Contagiosum†
Pediculosis (Lice)† Poison Ivy/Oak‡
Tinea Corporis (Ringworm)† Shingles†
Continued
EXAM/EVAL
1815_Tab02_007-098.qxd 3/11/10 4:39 PM Page 84
EXAM/EVAL
Squamous Cell Carcinoma‡ Varicella (Chickenpox)†
†Image from Barankin, B., and Freiman, A.: Derm Notes. Philadelphia: F.A. Davis, 2006.
‡Image from Goldsmith, L., et al. Adult and Pediatric Dermatology: A Color Guide to Diagnosis
and Treatment. Philadelphia: F.A. Davis, 1997.
84
Common Pediatric Standardized Assessment Tools
Page 85
KEY: CR = criterion-referenced; NR = norm-referenced; NS = not specified

International Classification of Functioning (ICF) relevance:
B = body structures and functions, A = activity, P = participation
4:39 PM
Approx.
Age Limits Time Name Domain/Activities Type
32 wk* term NS Neurobehavioral Motor development, vigor, NR, B
Assessment of the scarf sign, popliteal angle,
Preterm Infant (NAPI) alertness and orientation,
irritability, cry, sleep, state
3/11/10
32 wk* 42 wk* 15 min Neonatal Tone/motor patterns, primi- CR, B

Neurobehavioral tives reflexes, behavioral
85
Examination (NNE) responses

32 wk* 42 wk* 30–45 min Assessment of Autonomic, motor, state, CR, B
Preterm Infants’ attention, self-regulation,
1815_Tab02_007-098.qxd
Behavior (APIB) response to facilitation

37 wk* 48 wk* 20–30 min Neonatal Behavioral Habituation, motor-oral, CR, B
Assessment Scale – truncal, vestibular, social-
third edition (NBAS) interactive
32 wk* 4 mo 25–40 min Test of Infant Motor Orientation of head in NR, B
EXAM/EVAL
Performance (TIMP) space, response to stimuli,
body alignment, antigravity
movement
*Gestational or postconceptual age; NB = newborn/neonate
Continued
Page 86
Approx.
Preterm NB 30 min Neurological Exam of Posture, eyes, power/ NR, B
the Full Term Infant passive movements,
(NEFTI) spontaneous/voluntary
4:39 PM
movements, state,
reflexes and responses
NB NB NS Neonatal Neurological Tone, primitive reflexes, NR, B
Exam (NEONEURO) neck support, DTRs, tremor,
alertness, fussiness
3/11/10
NB NB 30–45 min Einstein Neonatal Passive/active movement, NR, B

Neurobehavioral tone, reflexes, response to
86
Assessment Scale stimuli
(ENNAS)
NB 3 days 15 min Neurological Habituation, movement/ CR, B
1815_Tab02_007-098.qxd
Assessment of the tone, reflexes, neurobehav-

Preterm and Full-Term ioral characteristics
New Born Infant
(NAPFI)
NB 3 mo NS Neonatal Oral-Motor Oral motor abilities—rate, CR, B
Assessment Scale rhythmicity, jaw excursion,
EXAM/EVAL
(NOMAS) direction, ROM, timing of

tongue movement, tongue
configuration
Continued
Page 87
Approx.
NB 12 mo NS Neurological Evaluation Parent interview, examina- CR, B
of the Newborn and tion of head, posture, spon-
4:39 PM
Infant taneous movement, tone,

primitive reflexes, lateral
adduction maneuver
NB 12 mo 30–40 min Movement Muscle tone, reflexes, CR, B
Assessment of Infants automatic reactions,
(MAI) volitional movement
3/11/10
NB 12 mo NS Early Motor Pattern Muscle tone, reflexes, CR, B

Profile movement
87
NB 18 mo 15 min Alberta Infant Motor Gross motor developmental NR, A

Scale (AIMS) skills in prone, supine, sit-
ting, and standing
1815_Tab02_007-098.qxd
NB 18 mo NS Infant Neurobiological Resistance to passive CR, B, A

International Battery movement, reflexes, equi-
(INFANIB) librium, milestones
NB 2 yr NS Carolina Curriculum Cognition, communication, CR, A
for Infants and social/adaptation, FM, GM;
EXAM/EVAL
Toddlers with Special also a version for
Needs—Second preschoolers (2–5 yr)
Edition (CCITSN-II)
Continued
Page 88
Approx.
NB 2 yr 15–20 min Milani-Comparetti Locomotion, sitting, stand- NR, B, A
Motor Development ing, evoked responses (equi-
Screening, 3rd edition librium protective extension,
4:39 PM
(M-C) righting, primitive reflex)

NB 3 yr NS Infant Toddler GM, FM, cognitive, CR, B, A
Developmental language/communication,
Assessment (IDA) self-help, emotion/affect,
social adaptation, personal-
ity traits, coping
3/11/10
NB 3.5 yr 15–30 min Toddler and Infant Mobility, motor organiza- NR, B, A
Motor evaluation tion, stability/functional per-
88
(TIME) formance, social emotional
NB 5 yr NS Developmental Cognition, GM, FM/ CR, B, A
Programming for perceptual, language,
1815_Tab02_007-098.qxd
Infant and Young social-emotional, self-care

Children (DPIYC)
NB 5 yr 45–60 min Peabody Reflexes, stationary, loco- NR, B, A
Developmental Motor motion, object manipula-
Scales—2 (PDMS) tion, grasping, visual-motor
integration
EXAM/EVAL
NB 6 yr 10–20 min Developmental Cognition, communication, NR, B, A

Assessment of Young social-emotional, physical
Children (DAYC) development, adaptive
behavior
Continued
Page 89
Approx.
NB 6 yr NS Hawaii Early Learning Cognition, language, GM, CR, B, A
Profile Checklist (HELP) FM, social-emotional, self-
help; versions for 0–3 yr
4:39 PM
and 3–6 yr
NB 6.5 yr <20 min Denver Developmental Personal/social, FM/adaptive, NR, B, A
Screen Test-II (DDST-II) language, FM, five subjec-
tive test behavior items
NB 6 yr NS Vulpe Assessment Sensory/motor, develop- CR, B, A
3/11/10
Battery—Revised mental skill acquisition/

(VAB—R) caregiver characteristics,
89
performance analysis
NB 6 yr 30–120 min Assessment, Evaluation FM, GM, adaptive, cognitive, CR, B, A
and Programming social-communication, social;
1815_Tab02_007-098.qxd
Systems for Infants two versions (0–3 yr, 3–6 yr)

and Children (AEPS)
NB 7 yr NS Brigance Inventory of FM, GM, language, cognitive/ NR and
Early Development academic, self-help, social- CR, B, A
2nd edition (IED-II) emotional; screening test
versions also available for
EXAM/EVAL
infant/toddler, early pre-
school, preschool, kinder-
garten and first grade
Continued
Page 90
Approx.
NB 8 yr 1–2 hr Battelle Developmental Personal-social, adaptive, NR, B, A
Inventory, 2nd edition motor, communication,
4:39 PM
(BDI-2) cognition; also available as

screening test (30 min) and
in Spanish
NB Adult 45–60 min Scales of Independent Motor, social interaction, NR, B,
Behavior, Revised communication, personal A, P
3/11/10
(SIB-R) living skills, community liv-

ing skills, problem behavior
scale; early development
90
form available (15–20 min)
1 mo 3 yr NS Revised Gesell GM, FM, language, person- NR, B, A
and Armatruda al, social, adaptive
1815_Tab02_007-098.qxd
Developmental
and Neurologic
Examination
1 mo 3.5 yr 30–90 min Bayley Scales of Mental, motor, and behav- NR, B, A
Infant and Toddler ioral scales; subtests for
EXAM/EVAL
Development, 3rd social-emotional, adaptive

edition (BSID-III) behavior, caregiver report;
screening test also available
Continued
Page 91
Approx.
1 mo 5.5 yr 10–15 min Ages and Stages Gross motor, fine motor, NR, B, A
Questionnaire (ASQ) language, communication,
problem-solving, social,
4:39 PM
personal
2 mo 5 yr NS Infant Toddler Quality Physical activities, develop- NR, A, P
of Life Questionnaire ment, pain/discomfort,
(ITQOL) moods, behavior, future
health
3/11/10
4 mo 16 mo NS Infant Motor Screen Muscle tone, primitive CR, B

(IMS) reflexes, automatic
responses, symmetry
91
4 mo 18 mo 20 min Test of Sensory Reactivity to tactile deep CR, B

Function in Infants pressure, adaptive motor
(TSFI) function, visual/tactile inte-
1815_Tab02_007-098.qxd
gration, ocular motor con-

trol, reactivity to vestibular
stimulation
6 mo 7 yr NS Functional Self-care, mobility, cogni- NR, A
Independence Measure tion; training required;
EXAM/EVAL
for Children (WeeFIM) national database available
6 mo 6 yr NS Transdisciplinary Play Cognitive, social/emotional, CR, A
Based Assessment communication/language,
(TPBA) sensorimotor
Continued
Approx.
Page 92

6 mo 7.5 yr NS Pediatric Evaluation of Self-care, mobility, social NR, A, P
Disability Inventory function, modification scale
(PEDI) and caregiver assistance
scale
4:39 PM
7 mo 2.5 yr 10 min Infant Toddler Self-regulation, attention, CR, B, A

Symptoms Checklist eating/feeding, dressing,
(ITS) bathing, touch, movement,
listening/language, look-
ing/sight, attachment/
emotional functioning
3/11/10
1 yr 6 yr NS TNO-AZL Preschool Physical complaints, motor NR, A, P

Children Quality of Life functioning, autonomy, cog-
92
Questionnaire—Parent nitive functioning, social
Form (TAPQO-PF) functioning, emotional
functioning; children’s ver-
1815_Tab02_007-098.qxd
sion (8–15 yr) available

2 yr 18 yr 4 min Pediatric Quality of Physical, emotional, social, NR, A, P
Life Inventory school functioning, global
(PedsQL) health; includes child self-
report and parent proxy
versions
EXAM/EVAL
2 yr 18 yr NS Pediatric Outcomes Normal daily activities, NR, A, P

Data Collection expectations, happiness,
Instrument (PODCI) satisfaction, general health,
health change
Continued
Page 93
Approx.
2 yr Adult 10–15 min Beery-Buktenica Visual-motor integration NR, B
Developmental Test through copying geometric
4:39 PM
of Visual-Motor forms; short (2–8 yr) and

Integration—5th full format (>8 yr); also
edition (VMI) includes visual perception
and motor coordination
tests (additional 5 min each)
2.5 yr 6 yr 30–40 min Miller Assessment of Basic motor tasks, aware- NR, B, A
3/11/10
Preschoolers (MAP) ness of sensations, GM,

FM, OM, verbal and nonver-
93
bal cognition and language,

complex tasks
2.5 yr 6.5 yr 15 min FirstSTEP: Screening Cognition, language, motor, NR, A
1815_Tab02_007-098.qxd
Test for Evaluating social-emotional, adaptive

Preschoolers behavior; parent-teacher
scale
2.5 yr 8 yr 45–60 min Miller Function and GM, FM, visual-motor, NR, A, P
Participation Scales school-based activities
EXAM/EVAL
3 yr 5 yr 30 min DeGangi-Berk Test of Postural control, bilateral NR, B
Sensory Integration motor integration, reflex
(TSI)
Continued
Page 94
Approx.
3 yr 10 yr NS Sensory Profile (SP) Sensory processing, modu- NR, B
4:39 PM
lation, behavioral emotional

responses; also infant (0–36
mo), adolescent/adult, and
school companion (CR)
versions
3 yr 12 yr 15–20 min Test of Gross Motor Locomotor (run, jump, leap, NR, A
3/11/10
Development—2nd gallop, slide) object control

edition (TGMD-2) (hit ball with bat, dribble,
kick, catch, overhand throw,
94
underhand roll)
3 yr 14 yr 3–6 min Test of Visual Motor Visual-motor skills, eye- NR, B
1815_Tab02_007-098.qxd
Skills—revised hand motor accuracy,

(TVMS-R) motor control/coordination;
Upper Level version for
children >12 yr
3 yr 17 yr 20–40 min Movement Manual dexterity, ball skills, NR, B, A
Assessment Battery for static and dynamic balance;
EXAM/EVAL
Children, 2nd edition parent/teacher checklist

(Movement-ABC-2) available (5–12 yr)
Continued
Page 95
Approx.
4 yr 9 yr 3 hr Sensory Integration Form/space perception, NR, B
and Praxis Tests (SIPT) somatic and vestibular
sensory processing, praxis,
4:39 PM
bilateral integration/
sequencing; test usually
given over two sessions
4 yr 11 yr 45 min Developmental Test Form constancy, figure NR, B
of Visual Perception— ground, position in space,
3/11/10
2nd edition (DTVP) spatial relations, eye-hand

coordination, copying, visu-
al closure, visual-motor
95
speed; also adolescent/

adult version
4 yr 18 yr 5 min Test of Visual Visual—discrimination, NR, B
1815_Tab02_007-098.qxd
Perceptual Skills—Non memory, spatial relation-

Motor 3rd edition ships, form constancy,
(TVPS-3) sequential memory, figure
ground, closure
4 yr 19 yr 25 min Test of Visual Visual—discrimination, NR, B
EXAM/EVAL
Perceptual Skills memory, spatial relation-
3rd edition (TVPS-3) ships, form constancy,
sequential memory, figure
ground, closure
Continued
Approx.
Page 96

4 yr 21 yr 45–60 min Bruininks-Oseretsky Fine motor precision, fine NR, B, A
Test of Motor motor integration, manual
Proficiency— dexterity, bilateral coordina-
2nd edition (BOT-2) tion, balance, running
4:39 PM
speed and agility, upper

limb coordination, strength
4 yr adult 20 min Motor Fee Visual Matching, figure ground, CR, B
Perceptual Test, 3rd closure, visual memory,
edition (MFVPT-3) form discrimination
3/11/10
5 yr 12 yr 5–10 min/ School Function Participation, task supports, CR, A, P

scale Assessment (SFA) activity performance,
physical tasks, cognitive/
96
behavioral tasks
5 yr 13 yr NS Assessment of Life 12 dimensions of participa- CR, P
Habits for Children tion: communication, per-
1815_Tab02_007-098.qxd
sonal care, housing, mobility,

nutrition, fitness, recreation,
responsibility, education,
community life, interper-
sonal relationships
EXAM/EVAL
5 yr 15 yr NS Clinical Observations Screening test; slow CR, B

of Motor and Postural movements, arm rotation,
Skills, 2nd edition finger-nose touching prone
(COMPS) extension posture, ATNR,
supine flexion posture
Continued
Approx.
Page 97

5 yr 18 yr NS Child Health Physical functioning, role NR, P
Questionnaire (CHQ) functioning, bodily pain,
general behavior, mental
health, self-esteem, general
4:39 PM
health, parental impact,

family activities, family
cohesion; short form also
available
5 yr Any* 45–60 min Gross Motor Function Lying, rolling, sitting, crawl- CR, A
Measure (GMFM-88) ing, standing, walking, run-
3/11/10
ning and jumping; GMFM-

66 version also (interval
97
measure)
5 yr Adult NS Sensorimotor Rolling, belly crawling, bat CR, B, A
Performance Analysis the ball from three point,
1815_Tab02_007-098.qxd
(SPA) kneeling balance, pellets in

a bottle, paper/pencil task,
scissors task
5 yr Adult 5–15 min Full Range Test of Nonverbal, relate visual NR, B
Visual Motor stimuli to motor responses
Integration (FRVMI)
EXAM/EVAL
6 yr 21 yr NS Children’s Assessment Formal and informal activi- CR, A, P
of Participation and ties, recreational, physical,
Employment (CAPE) social, skill-based, and self-
improvement activities
*The GMFM is appropriate for children with cerebral palsy whose motor skills are at or below that which is typical of a 5-year-old.
Continued
Page 98
Approx.
4:39 PM
5 yr 15 yr 10–15 min Revised Developmental Parents rate their child’s NR, B, A

Coordination Disorder coordination and perfor-
Questionnaire mance of motor skills on
(DCDQ ‘07) a 5-point scale
8 yr 14 yr NS Self-Perception Profile 36 items, self-report, five CR, A, P
for Children (SPPC) scales: scholastic compe-
3/11/10
tence, social acceptance,

athletic competence, physi-
cal appearance, behavioral
98
conduct, measure of global
self-worth
1815_Tab02_007-098.qxd
8 yr 15 yr NS TNO-AZL Children’s Pain and symptoms, NR, B,

Quality of Life GM, autonomy, cognitive A, P
Questionnaire—Child functioning, social, global
Form (TACQOL-CF) emotional
8 yr Adult 20–40 min Canadian Occupational Self-perception of perfor- CR, A, P
Performance Measure, mance in areas of leisure,
EXAM/EVAL
4th edition (COPM) work, ADLs

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99
Selected Medical Diagnoses in Children
■ Common elements of pediatric diagnoses that may routinely involve
referral to rehabilitative professionals
■ Presented alphabetically in the following categories based on primary
etiology:
I. Musculoskeletal System
A. Arthrogryposis
B. Blount disease
C. Developmental dysplasia of the hip
D. Fractures
E. Juvenile idiopathic arthritis
F. Lateral discoid meniscus
G. Legg-Calvé-Perthes disease
H. Lower limb deficiency
I. Nursemaid’s elbow
J. Plagiocephaly
K. Overuse injuries
L. Scoliosis
M. Torticollis
II. Neuromuscular System
A. Acquired brain injury
B. Autistic spectrum disorder
C. Cerebral palsy
D. Developmental coordination disorder
E. Obstetrical brachial plexus paralysis
F. Spina bifida
G. Spinal cord injury
III. Cardiovascular and Pulmonary System
A. Asthma
B. Congenital heart defects
IV. Integumentary System
A. Burns
V. Genetic, Metabolic, Environmental
A. Achondroplasia
B. Angelman syndrome
C. Charcot-Marie-Tooth disease
DX
1815_Tab03_099-146.qxd 3/11/10 4:44 PM Page 100
DX
D. Childhood cancers
E. Cri du chat syndrome
F. Cystic fibrosis
G. Down syndrome
H. Ehlers-Danlos syndrome
I. Fetal alcohol syndrome
J. Inborn errors of metabolism
K. Hemophilia
L. Juvenile idiopathic arthritis
M. Marfan syndrome
N. Prader-Willi syndrome
O. Muscular dystrophies
1. Congenital
2. Facioscapulohumeral
3. Limb-girdle
4. X-linked (Duchenne, Becker, Emery-Dreifuss)
P. Neurofibromatosis
Q. Osteogenesis imperfecta
R. Sickle cell disease
S. Spinal muscular atrophy
For more information on rare diseases and disorders, consult the follow-
ing organizations:
■ Centers for Disease Control
■ http://www.cdc.gov/index.htm
■ GeneReviews at GeneTests
■ http://www.genetests.org
■ National Institutes of Health Office of Rare Diseases Research (ORDR)
■ http://rarediseases.info.nih.gov
■ National Organization for Rare Disorders (NORD)
■ http://www.rarediseases.org
100
1815_Tab03_099-146.qxd 3/11/10 4:44 PM Page 101
101
Musculoskeletal System
Arthrogryposis Multiplex Congenita (AMC)

Classification • Amyoplasia (most common)
• Distal arthrogryposis (seven subtypes)
Etiology Fetal abnormalities or maternal disorder causing
decreased fetal movements (akinesia); increased
connective tissue around developing joints; fixation
and contracture of joint; abnormal development of
muscle; possible factors include maternal infection
or hyperthermia, teratogens, amniotic fluid
abnormalities, single gene mutations
Presentation Cylindrical shape to extremities, absent skin creases,
thin subcutaneous tissue, atrophy or absence of
muscles, joint rigidity/contracture/ dislocation (distal
more than proximal; often symmetrical), may include
malformations (e.g. skeletal, cardiac, respiratory,
CNS, urinary)
Two common presentations:
• Dislocated hips, extended knees, equinovarus,
internally rotated shoulders, flexed elbows, flexed
and ulnarly deviated wrists
• Abducted and externally rotated hips, flexed
knees, equinovarus, internally rotated shoulders,
extended elbows, flexed and ulnarly deviated
wrists
Medications None known, other than routine meds associated
with orthopedic surgery
Medical Tests CPK levels, cytogenetic studies (with multiple-
system involvement), x-ray for skeletal deformities,
MRI to evaluate muscle mass; skin and muscle
biopsy; consult ophthalmologist (retinal
degeneration)
Medical Surgery to correct bony deformities, bone and
Management tendon transfers to enhance function/self-care;
consult neurologist, orthopedist, plastic surgeon
DX
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DX
Common Deformities in AMC
May have facial Shoulder

deformity internal
rotation
Wrist flexion
contractures Elbow contractures into
flexion or extension
Flexion and abduction
contractures, hip
dislocation common
Scoliosis may
be present
Club foot
Webbing of skin in areas Knee contractures into

of flexion contracture flexion or extension
Blount Disease (Tibia Vara)

Classification • Early onset or “infantile” (<3 yr old)
• Late onset or “juvenile” (4–10 yr old)
• “Adolescent” (>11 yr old)
• Severity is graded in six stages based on age and
x-ray findings (see Langenskiöld,1989)
Etiology Abnormal development of tibial epiphyseal plate
causes altered growth and bowing of the tibia;
irreversible pathologic change to bone occurs; risk
increases with obesity
Presentation Progressive bone deformity with tibia vara and
torsion, delayed ossification of medial epiphysis
and metaphysis of proximal tibia, histological
changes of the bone; can be unilateral or bilateral
Continued
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Blount Disease (Tibia Vara)—Cont’d
Medications None known, other than routine meds associated
with orthopedic surgery
Medical Tests X-ray of lower limbs (angle measurements done
from standing AP films: tibiofemoral, metaphyseal-
diaphyseal, metaphyseal-epiphyseal)
Medical Conservative until child is >2 yr old, then surgery
Management considered; osteotomy to realign tibia, disruption of
growth plate, limb lengthening
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Developmental Dysplasia of the Hip (DDH)

Classification • Subluxation—incomplete contact between
acetabulum and femoral head
• Dislocation—loss of contact between acetabulum
and femoral head
• Instability—hip subluxes or dislocates with passive
movement
• Teratological—antenatal dislocation
Etiology Not known definitively; several possible factors
include intrauterine position, female gender, firstborn,
breech presentation, genetic, oligohydramnios,
neuromuscular dysfunction; hip dislocations are
common with neuromuscular disorders (e.g., CP,
spina bifida), but are not considered DDH
Presentation Abnormal growth of the hip, decreased ROM;
pseudoacetabulum (associated with poor outcome),
leg length difference, uneven skin folds, may result
in antalgic gait; left side more often involved (owing
to the common intrauterine position against maternal
sacrum, forcing hip into adduction); increased incidence
of metatarsus adductus and torticollis
Medications None known
Medical Tests Test for hip instability at birth and well-baby visits
(Ortolani and Barlow maneuvers), ultrasound (in
younger child), x-ray (in older child), MRI
Medical Conservative management (bracing), then surgery
Management after age 2 yr if needed
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Barlow Test: adduction and compression
Ortolani Test: distraction and abduction
Fractures—Growth Plate/Physeal
Classification Salter-Harris classification:
• Type I—longitudinal split, separation of epiphysis
from metaphysis, disruption to hypertrophic zone,
may be difficult to detect on x-ray
• Type II—partial split through metaphysis with
triangular bone fragment (most common type)
• Type III—involves physis, extends through
epiphysis to the joint, can disrupt anatomical
alignment
• Type IV—oblique split through metaphysis, physis,
and epiphysis; extends to joint
• Type V—compression injury to physis, very difficult
to detect on x-ray, may be accompanied by
diaphyseal fracture (rare)
• Type VI—injury to peripheral physis, formation of
bony bridge and possible angular deformity (rare)
Continued
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Fractures—Growth Plate/Physeal—cont’d
Etiology Injury/trauma (compression, shear, tension) causes
disruption in physis of long bone (largely
cartilaginous)
Presentation Localized pain, redness, swelling; decreased
willingness to bear weight or use involved limb;
deformity may be present
Medications NSAIDs
Medical Tests X-rays, MRI, CT, bone scans
Medical Types I and II usually managed with closed reduction
Management and casting; types III and IV may need open reduction
and fixation; types V and VI need surgical repair and
possible physeal bar resection to prevent deformity
Salter-Harris Growth Plate Fracture Classification
I II III IV V
Juvenile Idiopathic Arthritis (JIA)

Classification • Pauciarticular or oligoarticular—affecting
<4 joints at onset, peak age of onset is 1–2 yr,
usually asymmetric
• Polyarticular—affecting >5 joints at onset,
peak age of onset 2 yr (RF- subtype), >8 yr
(RF+ subtype), usually symmetric
• Systemic—multiple joint and organ (liver,
spleen) involvement
Also known as juvenile rheumatoid arthritis (JRA)
Continued
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Juvenile Idiopathic Arthritis (JIA)—cont’d
Etiology Autoimmune disorder; possible factors include
genetics, trauma, infection
Presentation Joint pain, stiffness, erythema, swelling; weakness,
decreased activity and function; fever (spike in
the evenings) and rash can accompany systemic
form; eye involvement (uveitis) can accompany
pauciarticular form; diagnosis is made based on
criteria: arthritis in at least one joint for 6 wk, onset
<16 yr old and exclusion of other types of arthritis
Medications NSAIDs, glucocorticoids (including slow-acting
antirheumatic drugs), COX-2-selective inhibitors,
disease-modifying antirheumatic drugs (e.g.,
methotrexate), anti-TNF (tumor necrosis factor)
therapy
Medical Tests Blood testing, x-ray, ultrasound, MRI, bone scan
Medical Primarily pharmacotherapeutic and referral to
Management rehabilitation therapies; orthopedic surgical
intervention for severe joint dysfunction (soft
tissue release, osteotomy or fusion, synovectomy,
joint replacement); consult orthopedist,
ophthalmologist
Joint Involvement in JIA
Bone
Bone, capsule and ligaments

are eroded
Inflamed synovium becomes

thickened and stiff
Cartilage Inflamed tendon sheath
Synovial fluid
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Lateral Discoid Meniscus

Classification • Complete—meniscus covers entire lateral tibial
plateau
• Incomplete—meniscus extends beyond tibial
plateau
• Wrisberg type—absence of meniscotibial
ligaments to posterior horn (responsible for
classic “popping” in knee flexion and extension)
Etiology Unknown, believed to be a result of faulty
embryological development or deficiency in
normal attachments, which lead to abnormal
growth and hypertrophy
Presentation Knee pain and swelling, snapping and locking of
knee; these symptoms in children <10 yr old are
highly suggestive; in children >10 yr, meniscal
tears must be considered
Medical Tests X-ray, MRI, arthroscopic examination
Medical Surgical intervention (partial/full meniscectomy or
Management repair) only if symptomatic (pain, instability, tear)
Incomplete
Complete
Wrisberg
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Legg-Calvé-Perthes Disease
Classification Catterall classification:
• Stage I—clinical diagnosis without findings on
x-ray
• Stage II—sclerosis, possible cystic change,
preservation of femoral head shape
• Stage III—loss of femoral head integrity
• Stage IV—loss of femoral head and acetabular
integrity
Etiology Idiopathic osteonecrosis of capital femoral
epiphysis of femoral head; boys three to five
times more affected than girls (typically 4–10 yr
old), increased incidence with low birth weight;
condition is self-limiting; contributing factors
include trauma, steroid use, DDH, sickle-cell
crisis, toxic synovitis, SCFE
Presentation Limp (abductor lurch) with pain in hip, groin,
thigh, or knee; decreased ROM (internal rotation
and abduction of hip); bilateral in 10%–20%;
femoral head abnormalities may result
Medications Pain management
Medical Tests X-ray, MRI, CT, nuclear imaging, ultrasound (r/o
transient synovitis), blood tests (r/o infection)
Medical Decrease weight-bearing, joint protection (bracing
Management with hip in internal rotation and abduction),
await natural course (revascularization); surgical
intervention in more severe cases to preserve/
restore femoral head shape
Detail of Hip Joint

Pelvis
Acetabulum
(socket) Femoral head
(bone affected
by Perthes’ disease)
Cartilage
Femur
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Lower Limb Deficiency

Classification • Longitudinal—reduction or absence within long
axis (e.g., proximal femoral focal deficiency
[PFFD])
• Transverse—absence across the width of limb (full
or partial, e.g., apodia [absence of hand or foot])
See Orthotics and Prosthetics tab for associated
terms
Etiology Unknown; suspected causes are injury to neural
crest cells in embryological development, defect
of the proximal growth plate, maternal exposure
to thalidomide, premature amnion rupture,
vascular supply disruption, genetic causes
Presentation Abnormal limb formation or absence of limb
segments, other skeletal deformities and congenital
heart defects may be present
Medical Tests X-ray, workup for cardiac abnormality
Medical Conservative management (orthotic or prosthetic
Management devices), surgical correction, limb lengthening,
arthrodesis, rotationplasty, elective amputation
Phocomelia: examples of a longitudinal deficiency
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Nursemaid Elbow
Classification N/A
Etiology Soft tissue damage to the elbow resulting from
radial head slipping under annular ligament
(usually from swinging or pulling from the distal
arms), young children are predisposed because
of the weakness of this ligament; child refuses to
use affected extremity
Presentation Child may complain of pain and refuses to use
and protects affected arm, holding it in flexion
and support by opposite arm; redness, swelling,
warmth, and swelling are noted, most common
in children 1–4 yr old, usually unilateral; point
tenderness over radial head
Medications Pain medications typically not needed
Medical Tests X-ray
Medical Closed reduction, parent/caregiver education
Management
Nursemaid Elbow
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Plagiocephaly—Misshapened Head/Skull
Classification • Positional plagiocephaly
• Craniosynostosis
• Scaphocephaly—premature closure of sagittal
suture
• Plagiocephaly—premature closure of coronal
suture (unilaterally)
• Brachycephaly—premature closure of coronal
suture (bilaterally)
Etiology Positional—intrauterine positioning, sleeping
position, torticollis; craniosynostosis—associated
with several congenital syndromes; from a primary
defect in ossification or failed brain growth
Presentation Misshapen head: scaphocephaly—long, narrow
head shape; plagiocephaly—asymmetrical head
shape, posterior flattening on one side;
brachycephaly—short, wide head shape
Medical Tests EMG, spine and brain MRI
Medical Positional—alternate sleeping position, monitoring,
Management helmet therapy (cranial remolding) in more severe
cases and where facial asymmetries are noted
(ideally started <6 mo old); craniosynostosis—
surgical removal of bone to correct deformity
(done ideally <9 mo old)
Normal Plagiocephaly Scaphocephaly Brachycephaly
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Common Overuse Injuries
Classification Lower extremity:
• Stress fracture—most common in the tibia,
fibula, and pars interarticularis
• Periostitis (“shin splints”)—strain of anterior or
posterior tibialis as a result of ballistic movement
with rapid deceleration
• Traction apophysitis—Osgood-Schlatter disease
(tibial tubercle), Sever disease (calcaneus),
Sinding-Larsen Johansson disease (distal pole
of patella); typical during time of adolescent
growth spurt
Upper extremity:
• Little league elbow—repetitive valgus stress
causes irritation to medial epicondyle, overgrowth
of radial head, osteochondritis, and possible
premature closure of physis
Etiology Repetitive submaximal stress on normal tissues;
contributing factors include overtraining, excessive
levels of physical activity, muscle imbalance,
growth spurts; can have long-term effect on
growth and development
Presentation Pain, possible swelling, focal tenderness
(exacerbated with vibration from tuning fork—
stress) or may be more diffuse (periostitis)
Medications NSAIDs
Medical Tests X-ray, MRI, bone scan
Medical Rest, activity modification, immobilization
Management depending on diagnosis, alter biomechanical
alignment (orthoses); referral to rehabilitative
professional
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Overuse Injuries
Growth plate
and apophysitis of
tibia (Osgood-Schlatter)
Inflammation of
lower pole of patella
Growth plate (Singing-Larsen Johansson)
inflammation
of the
calcaneus
(Sever)
Scoliosis
Classification • Idiopathic—often first noted around time of
adolescent growth spurt (girls more frequently than
boys)
• Neuromuscular—as a consequence of neuromuscular
dysfunction
• Congenital—present at birth; may be associated with
vertebral and organ abnormalities (heart, kidney)
Etiology Causes of idiopathic scoliosis are unknown;
contributing factors include genetic, skeletal
abnormalities, chemical, neurological, muscular
impairments; severe cases of idiopathic scoliosis may
be associated with neurological impairments (e.g.,
syringomyelia, Chiari malformation, tonsillar ectopia);
neuromuscular scoliosis may be caused by underlying
neuromuscular condition or progression of symptoms
Continued
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Scoliosis—cont’d
Presentation Curvature of the spine (>10º) detected through
screening or x-ray; resultant postural asymmetries
(uneven shoulders, pelvic obliquity, leg length
difference, prominent ribs on one side); labeled for
the location (section of vertebral column involved),
type and number of curves (s or c, single or double),
and direction (convexity to the right or left)
Medical Tests Forward bend test/screening; x-ray, MRI
Medical Monitor growth and curve progression, conservative
Management management (bracing); surgical correction, bony fusion
Cobb Angle (Severity of Curve) and Risser Grades (Indication of Skeletal Maturity)
Most tilted
vertebra
90° above apex
Apex
Cobb angle
90° Most tilted

vertebra
below apex
III IV
V
II
Risser grades
I
Right Left
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Slipped Capital Femoral Epiphysis (SCFE)

Classification Southwick angle (measured via x-ray)
• Normal—12º
• Mild—<30º
• Moderate—30–50º
• Severe—>50º
Etiology Dislocation or slippage of femoral head at upper epiphyseal
plate; can be related to trauma, but is also associated with
obesity and weakness of growth plate; affects boys two
times more often than girls and typically during adolescent
growth spurt (10–15 yr old)
Presentation Intermittent limp, hip or knee pain, may refuse to bear
weight, decreased ROM (obligatory external rotation of hip
during flexion is pathognomonic); 25%–40% are bilateral
Medical Tests X-ray, MRI
Medical Surgical stabilization (pinning) soon after diagnosis,
Management immobilization and activity restriction after surgery may
be indicated
Slip Indications on AP View of Hip, Plain X-Ray
Capener’s sign:
Slip is detected when the
entire femoral metaphysis
is below the lower border
of the acetabulum
Trethowan’s line:
If a line from the superior
margin of the femoral neck
does not intersect the
femoral epiphysis leaving
~20% of the head lateral to
the line, a slip is suspected
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Torticollis
Classification • Congenital muscular torticollis
• Torticollis associated with neuromotor disorders
Etiology Unknown; potential causes include muscle fibrosis
because of decreased blood supply to muscle or
muscle compartment syndrome in utero; some
neurological conditions can cause similar neck
positioning
Presentation Unilateral tightening and shortening of sternoclei-
domastoid muscle results in neck flexion to side of
muscle involved and head rotation so that the face
turns to opposite side and is tilted upward; visible/
palpable swelling or mass in muscle may be evident;
child may be at risk for positional plagiocephaly
Medications Trial with Botox injection
Medical Tests Ultrasound
Medical Conservative management with positioning, exercise,
Management gentle stretching, soft collar/brace; in more severe,
resistant cases (with facial asymmetry), surgery may
be indicated (muscle lengthening, fusion of abnormal
vertebrae)
Child with His Right Sternocleidomastoid Involved
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Neuromuscular System
Acquired Brain Injury (ABI)

Classification • Traumatic (e.g., falls, accidents, assault or abuse)
• Nontraumatic (e.g., stroke, tumor, infection,
hypoxia, ischemia, poisoning)
Etiology Damage to the brain that can be focal or diffuse
and occur via various mechanisms (see under
Classification); closed brain injuries involve no break
in the skull; penetrating brain injuries are “open-head
injuries” and involve disruption of the skull; diffuse
axonal injury may occur where there is shearing and
tearing of axons from movement of the brain within
skull (e.g., coup and contrecoup lesions)
Presentation Can range from mild (concussion) to severe (coma,
death); may involve an initial and perhaps prolonged
loss of consciousness; residual deficits in cognitive,
motor, sensory, perceptual, language, social, and
regulatory functions; epilepsy occurs in 2%–5% of
cases (most common with open-head injuries)
Medications Anticonvulsants; medically induced coma
Medical Tests Coma scales, CT, MRI, medical monitoring (e.g.,
intracranial pressure [ICP], central perfusion pressure,
brain oxygenation)
Medical Initial medical stabilization and examination for other
Management injuries; induced hypothermia has not been found
helpful in pediatric patients; shunting to relieve ICP;
surgical intervention if needed; referral to rehabilitation
professionals
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Bleeding
Bruising
Skull Contra Coup

Brain stem swelling
fracture and tearing
Coup
Autistic Spectrum Disorders (ASD)/

Pervasive Developmental Disorder (PDD)
Classification Diagnostic criteria are provided in DSM-IV for:
• Autistic disorder
• Asperger’s syndrome
• PDD-NOS (not otherwise specified)
• Rett’s syndrome (rare, mostly girls, onset 6–18 mo;
gene mutation identified)
• Child disintegrative disorder (CDD) (rare, mostly boys,
onset 3–4 yr)
Etiology Unknown; factors under investigation include exposure
to heavy metals (mercury), structural abnormalities of
the brain, neurotransmitter function, genetics
Presentation Dysfunction in three distinct areas with varying severity:
social interactions; communication (verbal and nonverbal);
repetitive behaviors; may be hyporeactive or hyperreactive
to sensory experiences and may have atypical movement
patterns; most common types are typically diagnosed
between 1–3 yr; complications include seizures, mental
retardation, fragile X syndrome, tuberous sclerosis; Rett’s
syndrome and CDD—symptoms appear after a period of
normal development; hand wringing characteristic of Rett’s
syndrome; both involve significant motor symptoms and
loss of language
Continued
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Autistic Spectrum Disorders (ASD)/Pervasive

Developmental Disorder (PDD)—cont’d
Medications Antipsychotics (risperidone), serotonin reuptake
inhibitors (off-label use, for behavioral symptoms;
some concerns about increased suicidal thoughts and
depression in teens); stimulants (for hyperactivity and
impulsivity)
Medical Tests Blood tests (e.g., elevated whole-blood serotonin in
33%); MRI and CT for brain abnormalities, EEG for
seizure activity
Medical Behavioral, educational, psychological, rehabilitative
Management services; initiate services as early as possible
Cerebral Palsy
Classification • By body region involved
• Diplegia
• Hemiplegia
• Quadriplegia
• By motor control impairment
• Hypotonic
• Spastic
• Athetoid
• Ataxic
• Gross Motor Function Classification System–Expanded
and Revised—five levels, based on age and ability to
self-initiate movement; specific emphasis on skills of
sitting, transfers, and mobility (Palisano, et al., 2007)
Etiology Nonprogressive disturbance of developing fetal or
infant (≤ 3 yr old) brain; includes neuropathy, brain
hemorrhage or anoxia, encephalopathy, congenital
CNS malformations, intrauterine infections or growth
restriction, birth asphyxia, preterm birth, multiple
gestation, maternal factors (thyroid abnormality,
mercury exposure, iodine deficiency)
Continued
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Cerebral Palsy—cont’d
Presentation Deficits in motor control, postural control, sensory and
perceptual function, communication, and cognition that
manifest in delayed motor development; seizure disorder
common; complications include orthopedic alignment
issues, spasticity, cognitive and speech impairments
Medications Antispasmodics, anticonvulsants, Botox injections
Medical Tests MRI, CT of brain, EEG, hip and spine x-ray
Medical Monitor seizures and spasticity; orthopedic surgical
Management procedures (e.g., soft tissue releases, pelvic osteotomies,
derotational osteotomies, spinal fusions); consult
orthopedist, neurologist, gastroenterologist
Developmental Coordination Disorder (DCD)

Classification N/A; diagnostic criteria are provided in DSM-IV;
subtypes are under consideration (ICD-10 uses the
term “specific developmental disorder of motor
functioning”
Etiology Unknown at present, likely to be multifactorial, some
level of CNS dysfunction is expected; high incidence
of co-occurring conditions (e.g., ADHD, learning
disabilities)
Presentation Deficits in motor coordination that are markedly
below what would be expected for age and cognitive
function (and are not explained by other known
disorders), but that do not prohibit achievement of
basic motor milestones; children do not outgrow the
condition and typically develop difficulties in social
adjustment and self-esteem
Medications None known for DCD specifically
Medical Tests None known
Medical No specific medical management, monitor for
Management psychosocial adjustment issues
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Pure
Pure ADHD
DCD (8%)
(23%) 9%
20%
6%
19%
Pure
Dyslexia
(17%)
Incidence of co-occurring conditions according to Kaplan (1998)
Obstetrical Brachial Plexus

Paralysis (OBPP) Injuries
Classification • Erb’s palsy (C5–C6—upper plexus)
• Klumpke palsy (C7–T1—lower plexus)
• Erb-Klumpke palsy—mixed upper and lower plexus
(C5–T1)
• Nerve injury can be classified as 1st through
5th degrees (based on Sunderland, 1951)
Etiology Trauma to upper extremity during or after birth;
excessive lateral traction of the head away from the
shoulder with avulsion or rupture of nerve roots/trunks,
associated vaginal birth (vertex presentation primarily),
large birth weight, and presence of shoulder dystocia;
other factors include intrauterine pressure neuropathy
caused by fetal position on the maternal pelvis
Continued
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Obstetrical Brachial Plexus Paralysis
(OBPP) Injuries—cont’d
Presentation Motor and sensory deficits based on distribution of
nerve/nerve roots involved; total plexus involvement
results in a flail upper extremity; upper plexus
involvement results in shoulder internal rotation, hand
and wrist flexion, and no movement of the shoulder or
elbow (waiter’s tip); in lower plexus involvement may
see eyelid ptosis and papillary miosis (Horner syndrome);
some spontaneous recovery is expected
Medical Tests MRI, chest x-ray (phrenic nerve paralysis), fluoroscopy
of diaphragm, EMG and NCV not as helpful as in plexus
injuries in adults and older children
Medical Surgical reconstruction (neurolysis, nerve grafting, nerve
Management transfer) of plexus (if biceps function is not recovered
by 3–4 mo), surgical management can include nerve
transfers, nerve graph, and humeral relocation
Anatomy of the Brachial Plexus
Musculocutaneous nerve
(muscles of upper arm)
Axillary nerve
(muscles of shoulder)
Radial nerve (muscles of

Location of injury lower arm and hand)
for Erb’s palsy
Median nerve
Location of injury (muscles of hand)
for Klumpke’s C4
palsy
C5 C7
C6
C8
T1
Ulnar nerve
(muscles of lower
arm and hand)
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Spina Bifida
Classification • Spina bifida aperta—open lesion/cystic mass visible
• Meningocele—vertebral abnormality, sac contains
CSF and meninges (dura and arachnoid)
• Myelomeningocele—vertebral abnormality, sac
contains spinal cord, meninges, and CSF
• Spina bifida occulta—bony abnormality, intact
overlying skin, can be accompanied by various
cutaneous abnormalities (e.g., lipoma, hemangioma,
hair tuft)
Etiology Failure of neural tube to close (caudally) in
development in utero; various factors, including
teratogens, genetic predisposition, and folic acid
deficiency, are possibly implicated
Presentation Motor and sensory loss at and around the level of
the deformity, foot deformities; complications
include spinal curvature, hip deformities, neurogenic
bladder, hydrocephalus (Arnold-Chiari II
malformation), tethered cord, cognitive impairment
Medications Antibiotics (shunt, bladder infections), anticonvulsants,
anticholinergics and alpha-adrenergic antagonists
(bowel/bladder), growth hormone
Medical Tests X-rays (spine, hip, etc.), MRI (hydrocephalus)
urodynamic studies
Medical Surgical closure (first hours to days after birth);
Management shunt for hydrocephalus (observe for signs of shunt
failure); orthopedic surgery (soft tissue release, bony
alignment); bowel/bladder management (intermittent
catheterization, voiding schedules); monitor for signs
of tethered cord; management of skin integrity; consult
nutritionist (weight management), orthopedist,
neurologist
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Spinal Cord Injury
Classification American Spinal Injury Association (ASIA)
• A = complete, no sacral sparing (S4–S5)
• B = incomplete, sensory (no motor) preserved
below lesion level (including S4–S5)
• C = incomplete, motor preserved below lesion
level; most key muscles at grade <3*
• D = incomplete, motor preserved below lesion
level; most key muscles at grade >3*
• E = normal; motor and sensory functions intact
• Other syndromes include anterior cord, Brown-
Séquard, cauda equina, central cord, conus medullaris
Etiology Any insult to the spinal cord (e.g., trauma, tumor,
vascular compromise, infection, skeletal
abnormalities), results in loss of motor or sensory
function, or both, depending on area and level of injury
Presentation Spinal or neurogenic shock, loss of motor or sensory
function, bowel/bladder dysfunction, autonomic
dysreflexia
Medications Glucocorticoids (first 8 hours after injury), spasticity
management, bowel/bladder management, pain
control
Medical Tests ASIA examination, blood tests (hematocrit), urinalysis,
EMG, MRI, CT, x-ray of spine/pelvis and chest
Medical Screen for head injury and other injuries if SCI caused
Management by trauma; manage spasticity and sensory deficits;
monitor for autonomic dysreflexia, skin integrity,
heterotopic ossification; consult orthopedist,
neurologist, urologist
*Muscle grade of 3 = active movement against gravity for the full ROM.
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Cardiovascular and Pulmonary System
Asthma
Classification • Mild intermittent
• Mild persistent
• Moderate persistent
• Severe persistent
• Classification based on age and frequency of
symptoms, symptom control, and PFTs (see
Guidelines for Diagnosis and Management of
Asthma)
Etiology Triggered immune release of chemical mediators
causing constriction of bronchial muscles, increased
mucus production, swelling of mucous membranes
Presentation Wheezing, coughing (at night, with exercise, etc),
SOB, chest tightness, sputum production; can be
precipitated or aggravated by various environmental
allergens (e.g., smoke, pollen, dander, dust, mold)
and irritants, changes in weather, foods, viral
infection (RSV), exercise, stress
Medications Quick relief agents: rapid-acting beta2-agonists (also
for prevention of exercise-induced symptoms); relief
agents: short-acting bronchodilators; control agents:
Inhaled corticosteroids, long-acting bronchodilators,
leukotriene modifiers
Medical Tests PFTs, bronchial provocation tests, blood tests, chest
x-rays
Medical Stepwise approach to management of symptoms
Management (see Guidelines for Diagnosis and Management
of Asthma—National Heart Lung and Blood
Institute: NIH)
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Normal During an attack
Tightened
Bronchial muscle
tube
Trachea Excess
Muscle mucus
Bronchiole
Lung Inflamed
Mucus-lined
wall bronchial Alveoli filled with
Alveoli lining trapped air
Bronchial
tube
Congenital Heart Defects

Classification • Abnormal passages in heart or between vessels
• Ventricular septal defect (VSD)
• Atrioventricular septal defect (ASD)
• Patent ductus arteriosus (PDA)
• Disorder of the valves
• Aortic valve stenosis
• Pulmonary valve stenosis
• Tricuspid valve atresia
• Pulmonary valve atresia
• Ebstein’s anomaly (of the tricuspid valve)
• Abnormally placed blood vessels
• Transposition of great arteries
• Tetralogy of Fallot (pulmonary valve stenosis, VSD,
overriding aorta, right ventricular hypertrophy)
• Truncus arteriosus
• Coarctation of the aorta
• Structural malformation
• Hypoplastic left heart syndrome (mitral atresia,
ASD, undeveloped left ventricle)
Continued
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Congenital Heart Defects—cont’d

Etiology Various factors may contribute, including genetics,
maternal infection or diabetes, maternal use of drugs
or alcohol
Presentation Varies by condition, but can include heart murmur,
cyanosis of skin, lips, fingernails, SOB, fatigue, poor
weight gain
Medications Prostaglandin E1 may be prescribed to keep the
ductus open while awaiting surgery to repair a
cardiac abnormality
Medical Tests Pulse oximetry, echocardiogram, chest x-ray
Medical Cardiac surgery or catheterization may be indicated
Management for abnormal passages or valve dysfunction; surgical
repair of abnormally placed vessels or hypoplastic
left heart may be done immediately and may require
more than one surgery; heart transplant may be
necessary
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Integumentary System
Burns
Classification • First-degree—superficial, limited to the epidermis
• Second-degree—partial-thickness superficial or
deep, extends to the dermis
• Third-degree—full-thickness, complete involvement
of dermis
• Fourth-degree—most severe, extends beyond
subcutaneous tissue (to muscle, fascia, bone);
often lethal
• Extent of total body surface area involved
(determined by “rule of 9s” or the Lund and
Browder chart)
Etiology Thermal (can include inhalation injury), radiation,
electrical (may involve nervous and cardiac systems;
entrance and exit wounds, flash burns), chemical
(acid and alkali causes)
Presentation First-degree—minor pain, erythema, damaged
epithelium sheds in 5–10 days, no scarring
Second-degree—pain, erythema, blistering, 25–35 days
to heal, hypertrophic scarring with deeper burns
Third-degree—no pain owing to destruction of nerve,
eschar, no capillary refill, scar forms, and grafting
may be necessary
Medications Analgesics, sedatives, topical burn agents
Medical Tests Trauma protocol, chest x-ray, blood and urinalysis
tests, PFT/ABG
Medical Nutrition and fluid monitoring (hypothermia), cardiac
Management and respiratory monitoring, wound débridement,
escharotomy and fasciotomy, wound closures
(biological, biosynthetic, artificial, and cultured skin),
scar management; infants/children with major burns
should be managed at a regional burn center
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Genetic and Metabolic
Achondroplasia
Classification N/A
Etiology Autosomal-dominant mutation in fibroblast growth
receptor gene 3 causing abnormal cartilage formation
Presentation Short stature (nonproportional dwarfism), short arms
and legs with long trunk, trident hands, midfacial
hypoplasia (small midface with flattened nasal
bridge), prominent forehead, thoracolumbar gibbus,
true megalencephaly, caudal narrowing of
interpedicular spaces; may have spinal deformities
(scoliosis, increased lordosis) and hydrocephalus
Medications Growth hormone (Nutropin, Genotropin, Humatrope);
antibiotics for frequent otitis media
Medical Tests X-rays for bone alignment, MRI for hydrocephalus or
spinal cord compression
Medical Limb lengthening, laminectomy for spinal stenosis,
Management fusion for kyphosis
Achondroplasia
Prominent
forehead
Facial
features
Increased
Short lordosis
stature
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Angelman Syndrome
Classification N/A
Etiology Deletion of maternal copy of chromosome 15q11-q13
Presentation Jerky movements, hand flapping, protruding tongue,
bouts of laughter, developmental delays by 6–12 mo,
seizures, speech impairment, hyperactivity, small
head size, sleep disorders, movement and balance
disorders, cognitive limitations, severe speech
impairment, facial dysmorphisms
Medications Anticonvulsants
Medical Tests CT or MRI brain, EEG
Medical Seizure control; supportive care
Management
Charcot-Marie-Tooth (CMT) Disease

Classification • Hereditary sensory motor neuropathy (HSMN) type 1
A and B—disorder of peripheral myelination
• HSMN type 2—primarily neuronal/axonal
• HSMN type 3 (Déjérine-Sottas disease)—infantile
onset, severe demyelination with delayed motor skills
Etiology HSMN; types 1–3 are most common (four other types
are known, but very rare); caused by duplication or
mutations of specific genes on specific chromosomes
Presentation Type 1—distal weakness and atrophy (LE > UE),
decreased DTRs, foot deformity (pes cavus and claw
toe), may have sensory loss
Type 2—weakness of leg and foot muscle primarily,
sensory loss in distal extremities (may have pes planus)
Type 3—weakness and areflexia with definite sensory
loss, may have sensory apraxia
Medications For pain—NSAIDs, serotonin reuptake inhibitors,
sodium channel blockers
Continued
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Charcot-Marie-Tooth (CMT) Disease—cont’d

Medical Tests Genetic testing, CSF analysis (differentiates between
type 3 and the other types), EMG and NCV, nerve biopsy
Medical Surgical correction of foot and spine deformities
Management
Toes clawed
High arch
Foot length shortened Collapsed arch
Prominent metatarsal heads Prominent and wearbearing navicular
Pes Cavus Pes Planus
Childhood Cancers
Classification By system involved:
• Leukemia (33%)—most common types are acute
lymphocytic and acute myelogenous
• Brain and CNS (21%)
• Neuroblastoma (7%)—most common site of
occurrence is the abdomen (within 1st yr)
• Wilms tumor (5%)—affects one or both kidneys
(2–3 yr old)
• Non-Hodgkin lymphoma (4%–5%)
• Hodgkin lymphoma (4%)—rare in children <5 yr old
• Rhabdomyosarcoma (3%)—occurs in embryonic
cells that give rise to voluntary muscle
• Osteosarcoma (3%)—primary bone cancer, may be
initially painless
• Retinoblastoma (<3%)—usually occurs in children
<4 yr old
• Ewing sarcoma (1%)—primary bone cancer,
typically painful
Continued
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Childhood Cancers—cont’d
Etiology Unchecked growth of abnormal cells owing to damage
of cell DNA (gene mutation), may metastasize to other
sites through the blood or lymph; possible causes are
genetic, environmental exposures, lifestyle factors
Presentation Red flags—unusual lump or swelling, unexplained
fatigue or paleness, pain, limp, unexplained fever
or illness, headache and vomiting, vision changes,
sudden weight loss, easy bruising
Medications Childhood cancers tend to respond well to
chemotherapy agents, and children tend to tolerate
them better than adults
Medical Tests Blood testing, imaging studies
Medical Surgical excision, bone marrow transplant,
Management chemotherapy agents, radiation, referral to a
member center of Children’s Oncology Group (COG)
www.childrensoncologygroup.org
Cri Du Chat Syndrome

Classification N/A
Etiology Partial deletion of short arm of chromosome 5p
Presentation Characteristic cry (like a cat) from larynx malformations;
mental retardation; developmental delay; microcephaly;
hypertonicity; premature graying of hair; small, narrow,
asymmetric face; dropped-jaw, open-mouth expression
secondary to facial laxity; short philtrum; malocclusion of
teeth; scoliosis; short 3rd–5th metacarpals; chronic upper
respiratory tract infections; otitis media; severe constipation;
hyperactivity; expressive language difficulties
Medications Antibiotics for URI, ear infections
Medical Tests X-ray for cranial and skeletal abnormalities, MRI brain;
swallowing studies (airway abnormalities);
echocardiogram
Medical Genetic counseling, monitor for congenital heart disease
Management
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Typical Facial Features of Cri Du Chat as Well as Other Genetic Syndromes
Microcephaly
Downward slant
to eyes
Wide set eyes
Short philtrum
Low set ears
Dropped jaw
Cystic Fibrosis (CF)

Classification N/A
Etiology Autosomal recessive; defects in CFTR gene; exocrine
gland dysfunction that involves multiple organs;
alterations in mucus resulting in viscous secretions
in respiratory, GI, exocrine systems
Presentation Chronic respiratory infection with progressive lung
disease, chronic cough, airway obstruction, sputum
production; pancreatic enzyme insufficiency,
obstructive liver cirrhosis; finger clubbing; GI
dysfunction, chronic liver dysfunction
Medications Pancreatic enzymes (for digestion), bronchodilators,
mucolytic agents, antibiotics for infection
Medical Tests Genetic testing, sweat test (for initial diagnosis),
PFTs, x-ray of chest and sinuses, sputum testing,
bronchoalveolar lavage
Medical Pulmonary clearance devices, surgery for respiratory
Management or GI complications, lung transplant; consult
gastroenterologist, endocrinologist, pulmonologist
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Body Systems Involved in Cystic Fibrosis
Sinus
Nasal cavity
Mouth Respiratory
Trachea system
Lung
Airway
Diaphragm
Esophagus
Stomach
Liver Digestive
Pancreas system
Intestines
Down Syndrome
Classification • Trisomy 21 (94%)
• Translocation (3.3%)
• Mosaic (2.4%)
Etiology Extra genetic material on chromosome 21
Presentation Facial characteristics, marked hypotonia, reduced
reflexes/reactions, developmental delays, feeding
problems, cardiac dysfunction, hip subluxation
Medications Thyroid hormone, antibiotics for frequent URIs and
otitis media, diuretics for cardiac disorders
Medical Tests Cardiac monitoring, audiology examination,
orthopedic monitoring with x-ray for atlantoaxial
instability, hip dislocation, patellofemoral dislocation,
pes planus, pes valgus
Medical Genetic counseling; obesity prevention; consult
Management dentist, endocrinologist, cardiologist, internist,
ophthalmologist
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Upward slanting
Relatively small palpebral fissures
shaped face with
flatter profile
Small ears
Epicanthal folds
Low nasal bridge

Small mouth
with protruding
tongue
Ehlers-Danlos Syndrome (EDS)

Classification • Classic—types I and II
• Hypermobility—type III (most common)
• Vascular—type IV (most severe)
• Kyphoscoliosis—type VI
• Arthrochalasis—types VII A and B
• Dermatosparaxis—type VII C
Etiology Depending on type, can be autosomal dominant or
recessive; gene mutation causes a defect in collagen
synthesis
Presentation Hypermobility type—flexible, unstable joints that
may dislocate or sublux easily, significant
ligamentous laxity, bruises easily, may have cardiac
dysfunction; classic types—feature hyperelastic skin
that tears and bruises easily, slow to heal, develops
abnormal scarring of the skin; types IV, VI, and VII A,
B, C are very rare
Medical Tests Skin/tissue biopsy diagnostic in all types except for
type III
Medical Skin protection, wound care, avoid joint injuries,
Management activity limitations
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Fetal Alcohol Syndrome (FAS)
Classification • FAS
• Fetal alcohol effects (FAE)—involvement to a lesser
degree than that of FAS
Etiology Maternal consumption of alcohol during pregnancy;
ethanol is thought to disrupt various processes in
fetal development
Presentation Low birth weight, failure to thrive, organ dysfunction,
small head circumference and typical facial features,
developmental delay, learning and cognitive
difficulties (including mental retardation), behavioral
and social problems, some may have epilepsy;
skeletal and cardiac abnormalities may exist
Medical Tests None specific to FAS
Medical Management of associated birth defects and
Management developmental problems
FAS
Small head
Low nasal bridge
Epicanthal folds Small eye openings
Flat midface Short nose
Thin upper lip

Smooth philtrum
Underdeveloped jaw
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Hemophilia
Classification • Hemophilia A—deficiency in clotting factor VIII
(most common)
• Hemophilia B—deficiency in clotting factor IX
• Hemophilia C—lack of functional clotting
Etiology X-linked genetic disorder of blood coagulation (types
A and B; type C is autosomal recessive); deficiency in
clotting factor prohibits fibrin formulation; prolongs
bleeding and healing time; bleeding into muscles,
joints, and closed spaces can occur
Presentation Prolonged bleeding from injury, tooth eruption
(infants), nosebleed; vomiting blood; pain, swelling,
loss of ROM with bleeding into joints and muscles;
easy bruising
Medications Infusions of deficient clotting factor; recombinant
clotting factor
Medical Tests Genetic testing, blood testing (prothrombin time,
activated partial thromboplastin time, factor assays)
Medical Prophylaxis (regular schedule) and on-demand
Management (during bleeding episodes) intervention with clotting
factor
Inborn Errors of Metabolism (IEM)

Classification • Disorders manifesting as intoxication or
encephalopathy
• Disorders of energy metabolism
• Disorders of complex molecules
Etiology Although each type is quite rare, IEMs in total effect
1:1000 newborns; ~100 types of IEM manifest in the
newborn period (of which only ~20 are treatable);
intoxication—accumulation of metabolites, essential
deficiency, defective transport; energy metabolism—
disruption at cytoplasm or mitochondria; complex
molecules—disturbance of synthesis or catabolism
Continued
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Inborn Errors of Metabolism (IEM)—cont’d
Presentation Presence of one or more of the following indicates
workup for IEMs: metabolic acidosis, hyperammonemia,
hypoglycemia; most common disorders include medium-
chain acyl-CoA dehydrogenase deficiency,
methylmalonicaciduria, galactosemia
Medications Dependent on the disorder; intravenous fluids with
glucose often given for hydration and electrolyte balance
Medical Tests Blood tests, urinalysis, CSF sampling; many states have
newborn screening programs to detect IEMs
Medical General aims of intervention are to interrupt catabolism
Management and remove toxic metabolites; hemodialysis and
extracorporeal blood purification may be necessary
Marfan Syndrome
Classification • Type I
• Type II
Type and location of gene mutation
Etiology Autosomal dominant disorder of connective tissue;
a type of fibrillin-1 mutation
Presentation Tall stature with extremities longer in proportion to
trunk, arachnodactyly, facial characteristics (long thin
face, prominent ears, forehead and jaw, asymmetry),
displacement of lens of the eye (ectopia lentis),
strabismus, cardiovascular disease (mitral valve
prolapse, aortic root dilation, aortic dissection),
hypermobility, spinal curvature, hip deformity and
chest/sternal deformities common
Medications Beta blockers for aortic dysfunction, hormone
therapy to induce puberty and stop growth
Medical Tests Genetic testing and counseling; x-ray of spine,
limbs, chest; echocardiogram; MRI of aorta, brain,
and spinal cord (dural ectasia)
Medical Mitral value corrections, spinal fusion/pectus repair,
Management consult cardiologist, ophthalmologist, orthopedist
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Prader-Willi Syndrome
Classification N/A
Etiology Deletion of paternal copy of chromosome 15q11-13
Presentation Hypotonia, delayed motor development, short
stature, initially experience feeding problems then
rapid weight gain from 1–6 yr, sleep disturbances,
growth hormone deficiency, precocious puberty,
facial dysmorphisms, behavioral problems
Medications Growth hormones
Medical Tests Genetic testing; brain MRI for hypopituitarism; DEXA
for osteoporosis; radiographs of spine, chest, limbs
Medical Orthopedic monitoring; management of weight gain/
Management obesity; adenoidectomy; address feeding and GI
complications; consult endocrinologist,
ophthalmologist, psychiatrist
Muscular Dystrophies
Congenital Muscular Dystrophy
Classification • With CNS involvement (Fukuyama, Walker-Warburg,
muscle-eye-brain)
• Without CNS involvement (merosin-deficient, merosin-
positive, integrin-deficient)
Etiology Autosomal recessive
Presentation Onset at birth or within 1st yr, general muscle dysfunction
with variable presentation depending on genetic defect;
severe hypotonia, feeding problems, spinal curvature,
respiratory difficulties, cognitive or learning difficulties,
seizures, cardiac and visual dysfunction are common
Medications Anticonvulsives, supportive care
Medical Tests CK levels, brain MRI, EMG, NCV, x-ray spine, muscle biopsy
Medical Seizure management; gastric tube feeding; consult oph-
Management thalmologist, cardiologist, pulmonologist; spinal fusions
Continued
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Muscular Dystrophies—cont’d
Facioscapulohumeral Muscular Dystrophy
Classification N/A
Etiology Autosomal dominant with gene mutation at 4q35
Presentation Onset in teenage years, initial facial muscle weakness,
which may be asymmetric; progression of weakness
to shoulder girdle, with scapular winging, humeral
subluxation; UE weakness proximal greater than distal
and LE weakness distal greater than proximal; Beevor’s
sign (navel moves cephalad with flexion of neck indicating
weakness of lower abdominal muscles); sparing of
extraocular and pharyngeal muscles; possible hearing
loss, retinal telangiectasias, atrial arrhythmias, restrictive
respiratory disease, mental retardation, seizures
Medications Beta2-adrenergic agonists and albuterol may improve
muscle strength and mass
Medical Tests Genetic counseling, serum creatine levels, EMG, NCV,
muscle biopsy
Medical Scapular fusion (fixed at 15º–20º) may be indicated in
Management patients with good deltoid function
Limb-Girdle Muscular Dystrophy
Classification • Type 1 (three subtypes)
• Type 2 (seven subtypes)
Etiology Type 1 is autosomal dominant, and type 2 is autosomal
recessive (most common)
Presentation Onset ranges from 6–8 yr to late teens, progressive
proximal weakness especially of shoulder and pelvic
girdles; respiratory and cardiac complications may develop;
given the 10 subtypes, presentations can vary widely
Medications To address cardiopulmonary dysfunction
Medical Tests Genetic testing, EMG, muscle biopsy
Medical Surgical correction of spinal curvature and contractures;
Management CPAP; pacemaker; consult cardiologist, pulmonologist
Continued
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Muscular Dystrophies—cont’d
Muscular Dystrophy—X-linked
Classification • Duchenne
• Becker
• Emery-Dreifuss
Etiology X-linked recessive with gene mutations at Xp21
(Duchenne, Becker) and Xp28 (Emery-Dreifuss)
Presentation Onset 3–5 yr old, progressive weakness (proximal greater
than distal) and loss of function, positive Gower sign,
calf hypertrophy; Duchenne—most severe and progressive;
Becker—less severe; Emery-Dreifuss—onset by 10 yr,
slower progression (primarily weakness in shoulder,
upper arm, calves), but cardiac complications common
(autosomal dominant type also exists)
Medications NSAIDs, corticosteroids, anticonvulsants, immunosup-
pressants, antibiotics for URI
Medical Tests Genetic counseling, EMG, muscle biopsy
Medical Monitor orthopedic, cardiac, respiratory status; soft tissue
Management releases and spinal fusion may be necessary because of
progression, supportive care
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Neurofibromatosis
Classification • Type 1 (hamartomatosis)—most common
• Type 2 (central neurofibromatosis)
Etiology Type 1—autosomal dominant mutation or deletion
in NF1 gene (long arm of chromosome 17); type 2—
mutation of NF2 gene (long arm of chromosome 22)
Presentation Diagnosed by 10 yr old; hamartomatous tumors of
any organ or system (most often in skin, eyes, and
CNS) that increase in number and size throughout
life, can see changes in pigmentation; type 1 has
fewer CNS tumors, usually skin (with the presence
of café au lait spots) and bone/joint most involved
(better prognosis) and is associated with LD, ADHD,
and visual-spatial motor deficits; in type 2,
meningiomas and acoustic neuromas are common
Medications None known, some trials of medications to slow
tumor growth have been done
Medical Tests Tissue biopsy; imaging to monitor bony
abnormalities and osteoporosis, MRI/CT of brain
Medical Excision of neurofibromas or spinal cord tumors;
Management management of CNS complications (seizure,
hydrocephalus); monitor for GI obstruction and for
hypertension; consult orthopedist (scoliosis),
ophthalmologist (congenital glaucoma)
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Osteogenesis Imperfecta (OI)

Classification • Type I—mild
• Type II—extremely severe (can be lethal, fractures
present in utero or at birth)
• Type III—severe
• Type IV—undefined
Etiology Autosomal dominant, mutation in COL1A1 and
COL1A2 genes (defect in type I collagen formation),
“brittle bone disease”
Presentation History of frequent fractures, often after little or no
trauma, decreased bone density, bowing of long
bones, tendency to bruise, characteristic blue sclera,
may have short stature; dental problems and hearing
impairment common; cardiac involvement also
possible
Medications Intravenous pamidronate to improve bone density
and reduce fracture incidence
Medical Tests Genetic testing; x-ray, DEXA; monitor for fractures,
scoliosis, and other bony deformities; vision and
hearing screening
Medical Prophylactic bracing/splinting (minimize
Management immobilization after fracture to prevent further
osteoporosis); surgical placement of intermedullary
rods in long bones; consult ophthalmologist,
audiologist, dentist, nutritionist, cardiologist
Sickle Cell Disease

Classification • Sickle cell trait or HbAS (one inherited gene)
• Sickle cell anemia or HbSS (two inherited genes,
one from each parent)
• Other rare forms include sickle-hemoglobin C, sickle
beta-plus-thalassemia, sickle beta-zero-thalassemia
Continued
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Sickle Cell Disease—cont’d
Etiology Autosomal recessive blood disorder producing
abnormal hemoglobin (HbS—from mutation in the
beta-globin gene on chromosome 11), which
eventually changes the shape of RBCs and impairs
their function
Presentation Bouts of severe pain caused by vaso-occlusive or
aplastic crises, fatigue, decreased resistance to
infection, slow growth, delayed puberty; serious
complications include cerebral infarction, AVN,
pulmonary hypertension, renal failure, gallstones
Medications Folic acid; hydroxyurea; pain control with NSAIDs,
analgesics for mild to moderate crises, IV opioids for
severe crises; antibiotics for infection
Medical Tests Hemoglobin electrophoresis to detect abnormal
hemoglobin
Medical Management of crises and complications, blood
Management transfusion, bone marrow transplant
Spinal Muscular Atrophy

Classification • Type I (Werdnig-Hoffmann)—acute infantile, onset
0–6 mo
• Type II—chronic infantile, onset 6–18 mo
• Type III (Kugelberg-Welander)—chronic juvenile,
onset >18 mo
• Type IV—adult onset
Etiology Autosomal recessive; mutation, deletion, or
rearrangement of one of the SMN genes, deterioration
of anterior horn cells in spinal cord
Presentation Progressive weakness and atrophy of limb and
respiratory muscles; bulbar (poor suck/swallow) and
brainstem (respiratory dysfunction) involvement
(occurs later with types II and III); types III and IV are
the mildest forms with much slower progression
Continued
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Spinal Muscular Atrophy—cont’d

Medications None known, controlled trials with valproic acid to
increase muscle strength have been done
Medical Tests Genetic testing, EMG and NCV, muscle biopsy, x-rays
of hips and spine to monitor deformities, PFTs
Medical Spinal fusion, pelvic stabilization, soft tissue releases,
Management supportive care
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Neonatal Intensive Care Unit—NICU
Apgar—measured at 1 and 5 min of life, give a total value between 0–10;
scores of 7–10 = normal; no established predictive value; indicator of need
for care after birth
0 1 2
Heart rate Absent <100 bpm >100 bpm
Breathing Absent Irregular, shallow, Good, crying
weak cry
Reflexes Absent Grimace Cough, sneeze
Muscle tone Flaccid Good tone, some Spontaneous,
flexion flexion of extremities well-flexed extremities
Color Blue, pale Body pink, extremities Entirely pink
blue
Quick Systems Review for Newborns
Neuromuscular/ Movement/range of all four extremities; presence of

musculoskeletal flexion, muscle tone, symmetry, primitive reflexes—
systems Moro, suck, rooting, grasp; anterior fontanel soft and
flat; length; weight
Cardiovascular HR and rhythm on auscultation, BP, color (may have
system transient acrocyanosis, otherwise pink), pulses—strong/
equal bilateral, capillary refill (<3 sec in peripheral
tissues, not nail beds), edema
Respiratory Auscultation of lungs (minimal fine crackles often right
system after birth), RR >60/min, any labor with respiratory
effort, nasal flaring or grunting
Genitourinary Boy—urethral opening at tip of penis; girl—labia minora
system and majora intact, hymenal tag may be visible
GI system Abdomen soft, no visible distention, cord attached and
clamped, anus patent
Eye, ears, nose, Eyes clear, palates intact, nares patent, ears in place
throat with correct alignment
Skin Color (pink or acrocyanotic); note skin lesions, bruising or
mottling, abrasions, birthmarks, caput/molding, integrity
LABS
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LABS
Signs of Stress in Newborns
• Bradypnea Respirations ≤30/min

• Tachypnea Respirations ≥60/min
• Abnormal breath sounds Crackles, wheezing, rhonchi, expiratory grunting
• Respiratory distress Nasal flaring, retractions, labored breathing,
apnea
Signs of Neonatal Abstinence Syndrome
• GI system Poor feeding, vomiting, regurgitation, diarrhea,

excessive sucking
• CNS Irritability, tremors, shrill cry, incessant crying, hyper-
activity, little sleep, excoriations on face, convulsions
• Metabolic, vaso- Nasal congestion, tachypnea, sweating, frequent
motor, respiratory yawning, increased RR >60/min, fever >37.2ºC
Common Equipment in NICU

Note: Numbers correspond to image that follows.
Apnea monitor (1) Electrode(s) placed on chest to monitor respiratory

rhythm, alarm alerts with apnea incidents
Arterial line (2) Catheter inserted and sewn in artery; monitors BP
directly, measures O2, CO2; access blood samples
Central line (3) Catheter inserted in vein up to the level of the
vena cava, used for delivery of fluids, meds,
blood
Electrocardiography (4) Electrodes attached to chest to monitor heart
rhythm
Endotracheal tube (5) Open-ended tube placed within trachea to
maintain open airway, may be connected
to a ventilator
Feeding tubes— Tube placed through the nose to the stomach
nasogastric, gavage (6) to allow fluid feeding, alternative route is a
tube through the mouth
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Intravenous line Catheter inserted into vein to deliver fluids
and meds
Isolette/warmer Enclosed heated Plexiglas bed
Nasal CPAP (continuous Delivers air through nasal prongs, flow of air
positive airway pressure) creates enough pressure to keep airway open
Phototherapy Special lights delivered via light source or blanket
on isolette, used to treat jaundice (to decrease
bilirubin)
PICC (peripherally Thin IV central line, usually placed in the arm
inserted central catheter) or leg
line
Pulse oximeter (7) Through probe on hand or foot, measures
amount of oxygen in the blood (O2 sat) and
may measure HR
Temperature Sensor attached to skin via an adhesive patch,
probe (8) used to monitor temperature, may be
connected to warmer to aid in regulating
amount of warming
Umbilical artery Small catheter inserted into umbilical artery to
catheter (9) collect blood and administer fluids and meds
Ventilator Mechanical device to facilitate breathing, can
be set for various support settings
5
2
(R) (L)
3 4
1 1
4 8
(Ground) 9
LABS
Page 150
New Ballard Score Maturational Assessment of Gestational Age

Neuromuscular Maturity
-1 0 1 2 3 4 5
4:50 PM
Posture
Square
Window
(Wrist) >90° 90° 60° 45° 30° 0°
3/11/10
Arm Recoil
150
180° 140°-180° 110°-140° 90°-110° <90°
LABS
Popliteal
1815_Tab04_147-183.qxd
Angle
180° 160° 140° 120° 100° 90° <90°
Scarf Sign
Heel To Ear
Source: Ballard, J.L., Khoury, J.C., Wedig, K., Wang, L., Eilers-Walsman, B.L., and Lipp, R.: New Ballard score,
expanded to include extremely premature infants. J Pediatr. 1991; 119:417-423. Information, instructions, and
videos at http://www.ballardscore.com/.
Page 151
Physical Maturity
Maturity Rating
sticky superficial cracking parchment Score Weeks
gelatinous leathery
4:50 PM
Skin friable smooth pink peeling pale areas deep

red cracking cracked
transparent translucent visible veins or rash,
rare veins no vessels wrinkled –10 20
few veins
–5 22
bald mostly
Lanugo none sparse abundant thinning areas bald
0 24
3/11/10
heel-toe
>50 mm faint anterior creases creases 5 26
Plantar 40–50 mm:-1 red transverse over
no crease ant. 2/3
151
Surface <40 mm:-2 marks crease only entire sole 10 28

barely flat areola stippled raised full areola 15 30
LABS
imperceptible areola areola 5–10 mm
Breast perceptible no bud
1–2 mm bud 3–4 mm bud bud 20 32
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well-curved formed 25 34
lids fused lids open sl. curved thick
loosely:-1 pinna; and firm
Eye/ear pinna flat pinna; soft; cartilage
soft but instant
tightly:-2 stays folded slow recoil
ready recoil recoil ear stiff 30 36
scrotum flat, scrotum testes in testes testes testes 35 38
Genitals empty upper canal descending down pendulous
smooth
(Male) faint rugae rare rugae few rugae good rugae deep rugae 40 40
prominent prominent majora and majora majora
clitoris
clitoris clitoris minora large cover 45 42
Genitals prominent
labia flat small enlarging equally minora clitoris
(Female) labia minora minora prominent small and minora 50 44
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LABS
Normal Pediatric Vital Signs by Age

Heart Rate (beats/min)
Age Awake Rest/Sleep Exercise/Fever*

Neonate 100–180 80–160 up to 220
Infant 100–180 75–160 up to 220
Toddler 80–110 60–90 up to 200
Preschooler 70–110 60–90 up to 200
School-age child 65–110 60–90 up to 200
Adolescent 60–90 50–90 up to 200
*NOTE: Heart rate increases in the presence of fever or stress/pain.
Grading of Pulses
0 = not palpable
+1 = difficult to palpate, thready, weak, easily obliterated with pressure
+2 = difficult to palpate, may be obliterated with pressure
+3 = easy to palpate, not easily obliterated with pressure (normal)
+4 = strong, bounding, not obliterated with pressure
Respiratory Rate (breaths/min)
Age Rate*
Neonate 35–65
Infant 30–60
Toddler 24–40
Preschooler 22–34
School-age child 18–30
Adolescent 12–16
*NOTE: Heart rate increases in the presence of
fever or stress/pain.
152
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153
Blood Pressure (in mm Hg)*
Age Systolic Diastolic

Birth—at 12 hr, <1000 g 39–59 16–36
Birth—at 12 hr, 3 kg 50–70 25–45
Neonate—at 96 hr 60–90 20–60
Infant 87–105 53–66
Toddler 95–105 53–66
School-age child 97–112 57–71
Adolescent 112–128 66–80
*NOTE: To estimate acceptable systolic BPs:
median (50th percentile) = 90 mm Hg + (2 ⫻ age [yr])
lowest (5th percentile) = 70 mm Hg + (2 ⫻ age [yr])
Temperature (ºF orally)
Indicative of Fever (when to call

Age Temperature health-care provider)
<1 mo 99.2 101.3
1–3 mo 99.4 101.4 (or >100.4 for >24 hr)
3 mo–2 yr 99.7 103 (or >101.4 for >3 days)
2–5 yr 98.6 101.4 for >3 days
5–12 yr 98.3 100.4
>13 yr 97.8 100.4
*NOTE: Rectal: Most accurate in infants, registers 1º > oral
Axillary: Toddlers up to age 4, registers 1º < oral
Oral: Preferred in children ≥5 yr old
Ear: Not as accurate in infants, many devices give oral or rectal temperature equivalent

Warning Signs in Fever—Refer to Health-Care Provider
Change in behavior, severe headache, constant vomiting/diarrhea, skin
rash, dry mouth, sore throat or earache that does not improve, stiff neck,
LABS
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LABS
fever that comes and goes over several days, stomach pain, high-pitched
cry, swelling on soft spot, irritable, unresponsive or limp, not hungry/will
not eat, wheezing/problems breathing, whimpering, pale.
Pain—”The Fifth Vital Sign”
Age Examples of Measures

Newborn Neonatal/Infant Pain Scale (NIPS); FLACC Scale; CRIES
Neonatal Postoperative Pain Scale
Infant Children’s Hospital Eastern Ontario Pain Scale (CHEOPS)
Toddler Wong-Baker FACES Pain Rating Scale
School-age child Visual Analog Scale (VAS—10 cm)
Adolescent Numeric Pain Intensity Scale (0–10), verbal pain
descriptors, Activity Tolerance Scale
Other Paediatric Pain Profile (for children with severe
neurological disability)
Wong-Baker FACES Pain Rating Scale
Universal Pain Assessment Tool

This pain assessment tool is intended to help patient care providers
assess pain according to individual patient needs.
Explain and use 0-10 Scale for patient self-assessment. Use the faces
or behavioral observations to interpret expressed pain when patient
cannot communicate his/or her pain intensity.
0 1 2 3 4 5 6 7 8 9 10
No Moderate Worst
pain pain possible pain
Wong-Baker
Facial
Grimace
Scale
0 1 2 3 4 5
No hurt Hurts Hurts Hurts Hurts Hurts
little bit little more even more whole lot worst
Activity No Can be Interferes Interferes Interferes Bedrest

Tolerance pain ignored with tasks with with basic required
Scale concentration needs
Source: Hockenberry, M.J., and Wilson, D.: Wong’s Essentials of Pediatric Nursing, ed. 8. St. Louis,
MI: Mosby, 2009.
154
Page 155
Laboratory Testing
Name of Test Relevance Reference Values for Children
Bilirubin, total serum In mg/dL; increased levels indicative Premature Term
of jaundice, liver disease, biliary Cord <2 <2
4:50 PM
obstruction; in newborns, increased 0–1 day 8 6

levels could indicate Rh or ABO
incompatibility; prolonged increase in 1–2 days 12 8
levels can lead to kernicterus, which 2–5 days 16 12
can result in MR, CP, blindness >5 days 20 10
Blood urea nitrogen (BUN) In mg/dL; indication of kidney Child—4–16
3/11/10
function; increased levels could Critical level—>40; increase of 20

indicate renal disease, GI bleeding, in 24 hr
155
dehydration, high-protein diet, CHF

Blood volume, whole blood In mL/kg; total blood volume including Boys Girls
LABS
RBC and plasma; to evaluate surgical 52–83 50–75
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blood loss, GI bleeding, diagnosis of

polycythemia vera
C-reactive protein In ng/mL; indicates inflammation Cord—52–1330
and infection; increased levels can 2–12 yr—67–1800
indicate CV disease, chronic
infection, MI, RA, rheumatic fever,
SLE, bacterial meningitis
Calcium—ionized (serum) In mEq/L; decreased levels may Newborn—3.7–7
affect cardiac rhythm and Infant—5–6
neurological status Child—4.5–5.8
Page 156

Cerebrospinal Pressure in mm Hg, WBC in μL; protein Normal pressure—50–100
fluid (CSF) in mg/dL; used in the diagnosis of WBC Count Protein
meningitis, intracranial or subarachnoid Premature 0–20 <400
bleeds, brain injury and other disorders
4:50 PM
Newborn 0–15 30–200

of the CNS Child 0–8 14–45
Chloride (serum) In mEq/L; increased levels can occur with Newborn—94–112
diarrhea, dehydration, total parenteral Infant—95–110
nutrition; decreased levels can occur Child—98–105
with vomiting, gastric suctioning,
3/11/10
ketoacidosis, kidney disease

Cholesterol In mg/dL; increased levels indicate Total LDL Triglycerides
156
atherosclerosis, hypothyroidism, biliary Infant 90–130 5–40
obstruction or cirrhosis, uncontrolled Child 10–135
LABS
DM, late pregnancy, stress; decreased Acceptable 130–170 <110

1815_Tab04_147-183.qxd
levels indicate hyperthyroidism,

Borderline 171–184 110–129
Cushing's syndrome, starvation,
malabsorption, anemia, acute infection High >185 >130
Copper (serum) In mcg/dL; increased levels can indicate Newborn—20–70
cancer, leukemia, Hodgkin's disease, Child—30–190
hyperthyroidism or hypothyroidism, Adolescent—90–240
anemia, RA, SLE, pregnancy, liver
cirrhosis; decreased levels can indicate
Wilson's disease, protein malnutrition,
chronic ischemic heart disease
Page 157

Cortisol In mcg/dL; increased levels indicate adrenal 8–10 am 4–6 pm
(plasma) tumor or cancer, Cushing's syndrome, Child 15–25 5–10
pregnancy, obesity, hyperthyroidism, diabetic
4:50 PM
acidosis; decreased levels indicate hypofunction

of adrenal or pituitary glands, RDS in LBW
infants, hypothyroidism
Creatine In mL/min; used to detect renal dysfunction; 85–135
clearance increased levels indicate hypothyroidism, HTN;
decreased levels indicate hyperthyroidism, renal
3/11/10
impairment, progressive muscular dystrophy,

ALS
157
Creatine In IU/L at 30°C; increased levels indicate MI, Boys Girls

phosphokinase skeletal muscle disease, CVA; CPK isoenzyme Newborn 65–580
LABS
(CPK) for muscle (CPK-MM) can implicate muscular
Child 0–70 0–50
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dystrophy, hemophilia; CPK isoenzyme for

heart (CPK-MB) can implicate cardiac
dysfunction, hypokalemia; CPK isoenzyme for
brain (CPK-BB) can implicate hemorrhage,
cancer, Reye's syndrome, seizures, cancer,
pulmonary embolism
Creatinine serum In mg/dL; indicates kidney function; increased Newborn—0.8–1.4
levels indicate renal failure, shock, SLE, cancer, Infant—0.7–1.7
leukemia, Hodgkin's disease, MI, diabetic
2–6 yr—0.3–0.6
neuropathy, CHF; decreased levels indicate
pregnancy, eclampsia >7 yr—0.4–1.2
Page 158

Cytomegalovirus Enzyme immunoassay for IgG and IgM; CMV Negative Weak Positive Positive
antibody (serum) is a herpesvirus and a common congenital <0.30 0.30–0.50* >0.60
(CMV) virus in infants; infants <6 mo could have *Can indicate recent infection in neonates
4:50 PM
maternal antibodies in their blood

Erythrocyte In mm/hr; used to evaluate inflammatory Newborn—0–2
sedimentation rate or malignant disease, rheumatic fever, MI; 4–14 yr—0–10
(ESR) increased levels indicate RA, rheumatic
fever, MI, cancer, Hodgkin’s disease, liver
dysfunction, hemolytic disease of
3/11/10
newborn, pregnancy
Fibrinogen In mg/dL; decreased levels result in Newborn—150–300
158
prolonged PT and PTT; increased levels Child—200–400
indicate acute infection, disease of
LABS
collagen, inflammatory disease, hepatitis;

1815_Tab04_147-183.qxd
decreased levels indicate severe liver

disease, leukemia, hypofibrinogenemia
Follicle-stimulating In mU/mL; increased levels indicate Child (prepubertal) 5–12
hormone (serum) precocious puberty, FSH-producing Women Men
(FSH) pituitary tumor, Turner's syndrome, mid-cycle
Klinefelter's syndrome, primary testicular
Adolescent/adult 10–90 4–25
failure; decreased levels indicate
neoplasms of ovaries, neoplasms of
testes, neoplasms of adrenals, polycystic
ovarian disease, hypopituitarism, anorexia
nervosa
Page 159

Glucose—fasting In mg/dL; monitor blood sugar for Newborn—30–80
blood (FBS) diagnosis and management of diabetic Child—60–100
conditions; increased levels indicate
4:50 PM
diabetes, Cushing's syndrome, MI,

stress, crush injury, burn, infection, renal
failure, pancreatic infection or cancer,
CHF, acromegaly; decreased levels
indicate hypoglycemia, cancer, adrenal
3/11/10
gland hypofunction, malnutrition,

alcoholism, cirrhosis of liver, hemolytic
disease, hyperinsulinism
159
Growth hormone In ng/mL; increased levels indicate Child—<10

(GH) gigantism, prematurity; decreased levels
LABS
indicate dwarfism, growth retardation,
1815_Tab04_147-183.qxd
hypopituitarism
Immunoglobulins In mg/dL; measure of antibodies—five Total Ig:
(serum) (Ig) groups: IgG, IgA, IgM, IgD, IgE; Infants Child to Adolescent
increased levels indicate various
Newborn—650–1450 1–3 yr—400–1500
infections, malnutrition, liver disease,
allergic reactions, autoimmune 3 mo—325–750 4–6 yr—700–1700
disorders; decreased levels indicate 6 mo—225–1200 6–16 yr—800–1700
various leukemias and other disorders
of blood
Page 160

Iron (serum) In mcg/dL; increased levels indicate Iron Total Iron Binding
various anemias, liver damage, Capacity
thalassemia, lead toxicity; decreased Newborn 100–270 60–175
levels indicate iron deficiency anemia, Infant 100–400
4:50 PM
cancer, RA, bleeding peptic ulcer, renal

failure, pregnancy, LBW infant, protein 6 mo—1 yr 40–100 100–135
malnutrition, chronic blood loss >2 yr 40–100
Lead in mcg/dL; increased levels indicative of Normal—10–20
lead poisoning, which can result in Acceptable—20–30
neurological impairment; heatstroke Excessive—30–50
3/11/10
Toxic—>50
Osmolality In mOsm/kg; increased levels indicate Serum Urine
160
dehydration, diabetes insipidus, (mOsm/kg/H2O)
hypernatremia, hyperglycemia, uremia; Newborn 100–600
LABS
decreased levels indicate fluid overload,

Child 270–290 50–1200
1815_Tab04_147-183.qxd
cancer of bronchus and lung, adrenal

cortical hypofunction
Partial In sec; used to monitor levels of Values in children are > adult level = 60–70
thromboplastin anticoagulants; increased levels indicate
time (PTT) hemophilia, cirrhosis of liver, vitamin K
deficiency, leukemia; decreased levels
indicate extensive cancer
Phenylalanine In mg/dL; used to diagnose Normal phenylalanine = 0.5–2; phenylalanine
(urine); phenylketonuria; increased levels also levels must be between 10–15, and infant at
phenylketonuria indicate LBW, hepatic encephalopathy, 3–6 wk old for PKU test to be accurate
(PKU) septicemia, galactosemia
Page 161

Potassium In mEq/24 hr; increased levels indicate Premature—4.2–7.6
(urine) excessive IV administration, renal Newborn—4.6–7.4
failure, infection, dehydration; decreased Infant—6–6.7
levels indicate vomiting, diarrhea,
Child—6.2–8
diuretic use, insulin administration,
4:50 PM
burns, ascites
Prothrombin In sec; used to evaluate anticoagulant Child—10–13
time (PT) therapy (warfarin); increased levels
indicate liver disease or cancer,
hemophilia, leukemia, CHF, hemolytic
disease of newborn; decreased levels
3/11/10
indicate thrombophlebitis, MI,

pulmonary embolism
161
Sodium (serum) In mEq/L; increased levels indicate Infant—134–150

excessive intake, Cushing's syndrome, Child—135–145
LABS
diabetes insipidus, excessive sweating;
1815_Tab04_147-183.qxd
decreased levels indicate diarrhea,

vomiting, nasogastric suction, syndrome
of inappropriate antidiuretic hormone,
diuretics, CHF
Thyroid function Provide information about thyroid and TSH T4
tests pituitary function By 3 days <25 μIU/mL
Includes: thyroid-stimulating hormone Newborn 11–23 mcg/dL
(TSH), triiodothyronine (T3), thyroxine
(T4), free T4, T3 resin uptake, thyroid 1–4 mo 7.5–16.5 mcg/dL
antibodies 4–12 mo 5.5–14.5 mcg/dL
1–6 yr 5.5–13.5 mcg/dL
6–10 yr 5–12.5 mcg/dL
Page 162

TORCH Screening for toxoplasmosis, rubella, If infant IgG > mother IgG and IgM present in
screening cytomegalovirus, herpes simplex; uses infant = positive for TORCH infection; rubella
titers of IgG and IgM and CMV are most common
Urinalysis Used to detect abnormal urine pH Specific Gravity
components and glycosuria and to Newborn 4.0–7.0 1.001–1.020
4:50 PM
diagnose renal disorders; urinalysis in

Child 4.5–8.0 1.005–1.030
newborns and children should be clear
in appearance, light straw to yellow in
color, and negative for protein, glucose,
ketones, and blood
3/11/10
162
CBC—Complete Blood Count
LABS

1815_Tab04_147-183.qxd
RBC count Bone marrow; increased levels indicate dehydration, 3.8–5.5

polycythemia vera; decreased levels indicate
hemorrhage, anemia, overhydration
Hemoglobin In g/dL; increased levels indicate dehydration, COPD, Newborn—13.5–17
polycythemia vera, CHF, severe burns; increased levels Infant—10–17
normal in high altitudes; decreased levels indicate Child—11–16
fluid volume excess, cancers and disorders of the
blood, blood loss, anemias (part of CBC)
Page 163

Hematocrit In %; indirect measure of Hgb content; Newborn—44–65
increased levels indicate dehydration, 1–3 yr—29–40
polycythemia vera; decreased levels indicate 4–10 yr—31–43
aplastic, hemolytic, pernicious, sickle cell, or
4:50 PM
folic acid deficiency anemia

RBC indexes • Mean corpuscular volume (MCV) MCV—77–95 µm3
• Mean corpuscular hemoglobin (MCH) MCH—23–33 pg/cell
• Mean corpuscular hemoglobin concentration MCHC—31%–37% Hgb [g]/dL RBC
(MCHC)
3/11/10
Used to detect macrocytic (increased levels)

and microcytic (decreased levels) anemias
163
RBC volume In %; differentiates some types of anemia 13.4% ± 1.2%

distribution width
LABS
Reticulocyte In % of RBC; decreased count indicates 0.5%–1.5%
1815_Tab04_147-183.qxd
count depressed bone marrow function; increased

count indicates erythrogenesis in response to
some stimulus, elevation can indicate chronic
hemolytic anemia
WBC count; In μL; used to detect types of anemia; Newborn—9000–30,000
leukocytes increased levels indicate acute infection, 2 yr—6000–17,000
tissue necrosis, leukemias, collagen diseases, 10 yr—4500–13,500
hemolytic and sickle cell anemias; decreased
levels indicate hematopoietic disease
(pernicious and aplastic anemias), viral
infection, malaria, SLE, RA, agranulocytosis
Page 164

Differential WBC • Neutrophils—increase indicates bacterial Neutrophils—35%
4:50 PM
infection
• Bands—immature neutrophils, may be increased Bands—3%–5%
with acute infection
• Eosinophils—increased in allergic disorders, Eosinophils—1%–3%
parasitic disease, certain neoplasms
• Basophils—allows increased blood to injured Basophils—0.075%
3/11/10
tissues while preventing excessive clotting

• Lymphocytes—involved in development of Lymphocytes—38%–50%
164
antibody and delayed hypersensitivity
• Monocytes—involved in early stages of
Monocytes–3%–7%
inflammatory reaction
LABS
1815_Tab04_147-183.qxd
Absolute Indication of body's capability to handle >1000

neutrophil count bacterial infections; ANC is calculated by
(ANC) multiplying WBC by total % of neutrophils
Platelet count In μL; used to detect types of anemia; increased 150,000–400,000
levels = thrombocytosis (polycythemia vera);
decreased levels = thrombocytopenia (aplastic,
iron deficiency, pernicious, folic acid deficiency,
sickle cell anemias)
Page 165
ABGs—Arterial Blood Gases

pH Expression of free hydrogen ion concentration 7.36–7.44
• In the blood, increased hydrogen ion
4:50 PM
concentration decreases pH and increases

acidity
• Decreased hydrogen ion concentration
decreases pH and increases acidity
• With compensated acidosis, pH is <7.40; in
compensated alkalosis, pH is >7.4
3/11/10
PaCO —partial
2 Respiratory component of acid-base balance; 35–45 mm Hg
pressure of alveolar ventilation when pH is abnormal, the
165
carbon dioxide respiratory systems works first (in minutes) to

correct or compensate
LABS
HCO —bicarbonate Metabolic component of acid-base balance;
3 24–28 mEq/L
1815_Tab04_147-183.qxd
takes longer (hours) to compensate through the

kidneys
PaO2—partial Amount of oxygen available to bind with 75–100 mm Hg
pressure of hemoglobin, with low pH less oxygen in
oxygen hemoglobin, PaO2 is decreased in respiratory
diseases
Base excess Amount of acid required to return blood pH to +2 to –2 mEq/L
normal
Anion gap Difference between the milliequivalents of >95%
cations and anions; an expression of the acid-
base balance/imbalance
Page 166
ABG Interpretation
Blood pH Normal = situation is either normal or compensated
Elevated = acidotic
Depressed =alkaline
4:50 PM
PaCO2 Elevated = acidotic

Depressed =alkaline
HCO3 Elevated = alkaline
Depressed = acidotic
3/11/10
Uncompensated pH is abnormal, either PaCO2 or HCO3 is abnormal, and the other is normal
Partially compensated pH is abnormal, PaCO2 and HCO3 are abnormal
166
Compensated pH is normal, PaCO2 and HCO3 are abnormal
LABS
1815_Tab04_147-183.qxd
PFTs—Pulmonary Function Tests

*NOTE: Reference values for PFTs are based either on a percentage (usually 75%–120%) or the 95% CI
(confidence interval) of the predicted lung capacity/volume based on the child’s age, height, and gender.
PFT Predicted Values for Boys and Girls calculators are available at: http://medcalc3000.com. Obtaining
accurate PFTs from children <2 yr old is difficult.
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167
Spirometric Values
Name of Test Description

Forced vital capacity (FVC) Total volume of air that can be exhaled
during a maximal forced expiration
effort (after a maximal inspiration)
Forced expiratory volume, Volume of air exhaled in the first
1 sec (FEV1) second under force after a maximal
inhalation
FEV1/FVC ratio (absolute) Percentage of the FVC expired in 1 sec
Forced expiratory volume, Volume of air exhaled in the 6 sec
6 sec (FEV6) under force after a maximal inhalation
Forced expiratory flow—over Average flow from the point at which
the middle one half of the 25% of FVC has been exhaled to the
FVC (FEF25%–75%) point at which 75% of FVC has been
exhaled; reflects flow in small airways
Maximum voluntary Maximum amount of air that can be
ventilation (MVV) inspired and expired over a sustained
interval (e.g., 15 sec); maximum
breathing capacity
LABS
Page 168
Lung Volumes
Expiratory reserve volume (ERV) Maximal volume of air that can be exhaled from end-expiration
of a normal breath
4:50 PM
Inspiratory reserve volume (IRV) Maximal volume of air that can be inhaled from end-inspiration
of a normal breath
Residual volume (RV) Volume of air remaining in the lungs after a maximal exhalation
Tidal volume (VT) Volume of air inhaled or exhaled during each respiratory cycle
Minute volume (MV) Total amount of air exhaled per minute
3/11/10
168
Lung Capacities
LABS
1815_Tab04_147-183.qxd

Functional residual capacity (FRC) Volume of air in the lungs at resting end-expiration
Inspiratory capacity (IC) Maximal volume of air that can be inhaled from the resting
expiratory level
Total lung capacity (TLC) Volume of air in the lungs at maximal inflation
Vital capacity (VC) Largest volume measured on complete exhalation after full
inspiration
Peak expiratory flow rate (PEFR) Maximum volume during forced expiration
Page 169
Interpretation of PFTs
Rating of Impairment by Interpretation of Spirometry
Pulmonary Function Results
4:50 PM
Restrictive
Obstructive Ventilatory Ventilatory
Normal Impairment Impairment
• Mild • FVC normal • FVC decreased or • FVC decreased
• FVC % of predicted: • FEV1 normal normal • FEV1 decreased
3/11/10
60%–79% • Absolute FVC1/FVC • FEV1 decreased or normal

• FEV1 % of predicted: >70% • Absolute FVC1/FVC • Absolute
60%–79%
169
<70% FEC1/FVC >70%

• FEV1/FVC % of predicted: Bronchodilator challenge Static lung volumes
60%–69% test indicated indicated
LABS
• Moderate • If FEV1 increases >12%
1815_Tab04_147-183.qxd
• FVC % of predicted: and FVC or FEV

40%–59% increases by 200 mL
• FEV1 % of predicted: = reversible airway
40%–59% disease
• FEV1/FVC % of predicted:
40%–59%
• Severe
• FVC % of predicted: ≤40%
• FEV1 % of predicted: ≤ 40%
• FEV1/FVC % of predicted:
≤ 40%
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LABS
ECG—Electrocardiography
Diagram of Normal Tracing
R
P = atrial depolarization
QRS = ventricular
depolarization
10 mm = 1 mV
T = ventricular
P T repolarization
Q S
0 0.2 0.4 0.6 0.8

Time (sec)
Basic ECG Interpretation

■ Determine ventricular rate
■ Determine QRS duration and shape
■ QRS between 0.08–0.12.sec = normal (two to three small boxes on
graph)
■ QRS >0.12 sec wide and bizarre = possible ventricular ectopy
■ QRS >0.12 sec with notched or rabbit ears = possible BBB
■ QRS preceded by one to two very narrow spikes = possible
pacemaker
■ Identify P waves and determine if a P wave precedes every QRS
complex
■ If >1 P wave precedes a QRS complex, determine the ratio of
P waves to QRS complex (4:1, 3:1, etc.)
■ Determine if P wave shape is consistent
■ Determine atrial rate and rhythm
170
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171
■ Determine PR intervals (PRI) and if they are consistent
■ PRI is consistent and between 0.12–0.20 sec (three to five small
boxes on graph) = normal
■ PRI is <0.12 = possible junctional rhythm
■ PRI is >0.20 sec, remains consistent in length from interval to
interval = possible primary AV block
■ PRI shows progressive lengthening until a QRS is dropped
= possible secondary AV block
■ PRI is not consistent, no correlation between P wave and
QRS = possible tertiary AV block
LABS
Page 172
ECG—Normal Values for Children

4:50 PM
HR QRS axis PR interval QRS interval R in V1* S in V1* R in V6* S in V6*

Age bpm degrees sec sec mm mm mm mm
1st wk 90–160 60–180 0.08–0.15 0.03–0.08 5–26 0–23 0–12 0–10
1–3 wk 100–180 45–160 0.08–0.15 0.03–0.08 3–21 0–16 2–16 0–10
3/11/10
1–2 mo 120–180 30–135 0.08–0.15 0.03–0.08 3–18 0–15 5–21 0–10
172
3–5 mo 105–185 0–135 0.08–0.15 0.03–0.08 3–20 0–15 6–22 0–10
6–11 mo 110–170 0–135 0.07–0.16 0.03–0.08 2–20 0.5–20 6–23 0–7
LABS
1–2 yr 90–165 0–110 0.08–0.16 0.03–0.08 2–18 0.5–21 6–23 0–7

1815_Tab04_147-183.qxd
3–4 yr 70–140 0–110 0.09–0.17 0.04–0.08 1–18 0.5–21 4–24 0–5

5–7 yr 65–140 0–110 0.09–0.17 0.04–0.08 0.5–14 0.5–24 4–26 0–4
8–11 yr 60–130 —15–110 0.09–0.17 0.04–0.09 0–14 0.5–25 4–25 0–4
12–15 yr 65–130 —15–110 0.09–0.18 0.04–0.09 0–14 0.5–21 4–25 0–4
>16 yr 50–120 —15–110 0.12–0.20 0.05–0.10 0–14 0.5–23 4–21 0–4
*V1 = right chest lead; V6 = left chest lead.
1815_Tab04_147-183.qxd 3/11/10 4:50 PM Page 173
173
Normal ECG Tracing in a Child
I aVR VI V4
II aVL V2 V5
III aVF V3 V6
25 mm/sec; 10 mm/mV
ECG—Abnormal Rhythms in Children
Definitions—Atrial Arrhythmias
• Sinus arrhythmia Heart rate varies with breathing, common in
children; usually benign, may be no other
symptoms or problems
• Sinus tachycardia Heart rate greater than normal for age; may
cause weakness, fatigue, dizziness, palpitations;
often temporary caused by exercise, stress, fever,
dehydration
• Sick sinus syndrome Sinus node sends signals either too slow or too
fast; can alternate between too slow and too fast
• Premature atrial Atrial pacemaker site above ventricles sends out
contractions (PACs) signal early; ventricles usually able to respond,
but result in irregular rhythm; commonly occur
as result of stimulants or medications
• Paroxysmal atrial Heart rate increased owing to series of early beats
tachycardia (PAT) from an atrial or junctional pacemaker site above
the ventricles; begins and ends rapidly, occurring
in repeated periods; can cause weakness, fatigue,
dizziness, fainting, or palpitations
• Atrial flutter Signals come from atria at fast but even rate, causing
ventricles to contract faster and increase heart rate;
if ventricles cannot respond, ECG shows signature
"sawtooth" pattern (two or more flutter waves
between each QRS complex); number of waves
between each QRS complex is expressed as a ratio
• Atrial fibrillation Electrical signals come from atria at very fast, erratic
rate; ventricles contract in irregular manner
LABS
1815_Tab04_147-183.qxd 3/11/10 4:50 PM Page 174
LABS
Definitions—Ventricular Arrhythmias
• Premature ventricular Electrical signal originates in ventricles, causes
contractions (PVCs) them to contract before receiving signal from
atria; common and often do not cause symptoms
or problems; if frequency of PVCs increases to
several per minute, weakness, fatigue, dizziness,
fainting, or palpitations may occur
• Ventricular tachycardia Electrical signal sent from ventricles at very fast
but regular rate; if heart rate is sustained at high
rate, weakness, fatigue, dizziness, fainting, or
palpitations may occur; may require an electrical
shock to "convert" the rhythm to a regular one
• Ventricular fibrillation Electrical signals are sent from ventricles at
very fast and erratic rate; ventricles are unable
to fill with blood and pump; life-threatening
because there is no pulse and complete LOC;
requires prompt defibrillation to restore
normal rhythm and function of heart; may
cause sudden cardiac death
Examples of ECG Tracings
Sinus Tachycardia
Premature Atrial Contraction (PACs)
174
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175
Atrial Flutter
Atrial Fibrillation
Premature Ventricular Contraction (PVCs)
LABS
Page 176
Radiology/Imaging*
Study Description
Plain Radiograph/X-ray Diagnostic images of anatomical features are produced by introducing
guide to radiodensity: an x-ray beam (ionizing radiation) to the body; the remnant radiation
• Air = black
4:50 PM
(the portion of the beam not absorbed by the body) is used to

• Fat = dark gray expose the film; x-rays of organ and circulatory systems require use
• Water = medium gray of a contrast medium; x-rays are done in at least two “views” for
• Bone = light medium gray diagnostic purposes; common views include: A/P (anteroposterior),
• Contrast media = very light gray LAT (lateral), OBL (oblique)
• Heavy metals = white
3/11/10
EXAMPLES:
A/P view of elbow, shows medial LAT view of elbow, shows supracondylar fracture in a 12-yr-old boy
176
epicondyle avulsion fracture
in 10-yr-old boy.
LABS
1815_Tab04_147-183.qxd
(Source: From Richardson, J.K., and Inglarsh, Z.A.: Clinical Orthopaedic PhysicalTherapy. Philadelphia: W.B. Saunders, 1994.)
*Unless otherwise specified, all radiological images from McKinnis, L.N.: Fundamentals of Musculoskeletal Imaging. Philadelphia: F.A. Davis, 2005.
Page 177
Study Description
CT scan (computed tomography) Application of x-ray that produces 2-D and 3-D images and can be
guide to viewing images: used to create cross-sectional views of body tissues; the x-ray
• Air = dark/black source and the film are moved in opposite directions resulting in
• Fat = dark gray/black 2-D images; CT scan views include axial, sagittal, and coronal;
4:50 PM
• Bone cortex = white contrast media may be used and can be administered IV, orally,
or rectally
• Bone marrow = dark/black
EXAMPLES:
Axial view—shows reactive Coronal view (right)—shows chondroblastoma in the proximal
sclerosis of left tibia owing to humerus of a 15-yr-old girl.
3/11/10
osteomyelitis in a 9-yr-old girl.

177
LABS
1815_Tab04_147-183.qxd
Page 178
Study Description
Fluoroscopy A type of “moving x-ray”; uses a plain x-ray, fluorescent screen, and
often video equipment; may be used to guide placement catheter
during procedures, to assess lung function, to detect obstructions or
malformations in airways and blood vessels, and in swallowing
4:50 PM
studies where a contrast medium such as barium may be used

EXAMPLES:
A type of fluoroscopy, showing a normal splenoportography.
3/11/10
178
LABS
1815_Tab04_147-183.qxd
Source: From Tortoricci, M., and Apfel, P.: Advanced Radiographic and Angiographic Procedures. Philadelphia: F.A. Davis, 1995.
Page 179
Study Description
MRI (magnetic resonance imaging) Hydrogen atoms in human tissues are excited when exposed to
guide to viewing images: radiofrequency pulses in a magnetic field; as they return to their normal
T1 T2 state, the atoms emit energy that is monitored by the MRI; provides a
method for examining physical and chemical properties of tissue; creates
• Air dark dark 3-D images with cross-sectional views; often used to study soft tissues
4:50 PM
• Fat bright dark of the CNS, spine, extremities, bones, and joints; contrast media can
• Bone marrow bright dark be used with MRI; other types of MRI include fMRI, MRA (magnetic
• Bone cortex dark dark resonance angiography), and MRS (magnetic resonance spectroscopy)
fMRI (functional MRI) fMRI allows for the patient to engage in movement or speech to
identify the location of the function and if appropriate its spatial
3/11/10
relationship to other lesions

EXAMPLES:
179
T1 and T2 weighted images of the T1 weighted image of the femoral head—shows avascular necrosis.
spine—show anterior herniation
of L5–S1.
LABS
1815_Tab04_147-183.qxd
Page 180
Study Description
Ultrasound Uses high-frequency sound beams to produce images of body structures;
provides no exposure to radiation; enables imaging of cartilaginous
structures that cannot be viewed on plain x-ray; with special software 2-D
images from several views can be used to construct 3-D images
Uses ultrasound to assess speed of blood flow through arteries and veins
4:50 PM
• Doppler ultrasound
• Echocardiogram Uses ultrasound, with or without contrast media, to view structures of
the heart; types include transthoracic and transesophageal
EXAMPLES:
Coronal ultrasound image Example of an echocardiogram.
showing moderate hip dysplasia
3/11/10
in a 4-wk-old infant.
180
LABS
1815_Tab04_147-183.qxd
Source: From Cochrane Miller, J.: Screening for general hip dysplasia. Radiology Rounds [serial online] 2004; 2(4). Available at:
http://www.massgeneralimaging.org/newsletter/april_2004/. Accessed July 20, 2009.
Page 181
Study Description
Scintigraphic (nuclear medicine) Use chemical isotopes to create images through scanning to study
studies organs and their physiological function; use very small amounts of
radiation and the ingestion, inhalation, or injection of a radiotracer
(radiopharmaceuticals), which gives off energy in the form of gamma
rays; can be superimposed on CT scans and MRI; images obtained
4:50 PM
through nuclear medicine may not be as clear or detailed, but are useful
in obtaining functional information about body organs and structures
• PET scan (positron emission Often used to measure blood flow, oxygen use, glucose metabolism
tomography)
• SPECT (single photon emission Uses a rotating camera and can be used to obtain cross-sectional
3/11/10
computed tomography) and 3-D information

• Bone scan Noninvasive imaging technique to view bones and bone metabolism
181
EXAMPLES:
Example of a bone scan of pelvis. Arrows show evidence of early myositis ossificans in the gluteus
LABS
medius muscle
1815_Tab04_147-183.qxd
Page 182
Recommended Immunization Schedule—Children 0–6 yr old

Recommended Immunization Schedule for Range of Certain high-risk
Persons Aged 0 Through 6 Years—United States 2009 recommended ages groups
1 2 4 6 12 15 18 19–23 2–3 4–6
Vaccine Age Birth month months months months months months months months years years
4:50 PM
Hepatitis B Hep B HepB HepB

Rotavirus Rota Rota Rota
Diphtheria, Tetanus,
DTaP DTaP DTaP DTaP DTaP
3/11/10
Pertussis
Haemophilus
influenzae type B Hib Hib Hib Hib
182
Pneumococcal PCV PCV PCV PCV PPSV
LABS
1815_Tab04_147-183.qxd
Inactivated Poliovirus IPV IPV IPV IPV

Influenza Influenza (yearly)
Measles, Mumps, Rubella MMR MMR
Varicella Varicella Varicella
Hepatitis A HepA (2 doses) Hep A series
Meningococcal MCV
Source: Centers for Disease Control and Prevention (CDC) http://www.cdc.gov/vaccines/recs/schedules/
child-schedule.htm.
Page 183
Recommended Immunization Schedule—Children 7–18 yr old

Range of Certain high-risk
Recommended Immunization Schedule for recommended ages groups
Persons Aged 7 Through 18 Years—United States 2009 Catch-up
immunization
4:50 PM
Vaccine Age 7–10 years 11–12 years 13–18 years

Diphtheria, Tetanus, Pertussis Tdap Tdap
Human Papillomavirus HPV (3 doses) HPV series
3/11/10
Meningococcal MCV MCV MCV

183
Influenza Influenza (yearly)
LABS
Pneumococcal PPSV
1815_Tab04_147-183.qxd
Hepatitis A HepA series

Hepatitis B HepB series
Inactivated Poliovirus IPV series
Measles, Mumps, Rubella MMR series
Varicella Varicella series
Source: Centers for Disease Control and Prevention (CDC) http://www.cdc.gov/vaccines/recs/schedules/
child-schedule.htm
Page 184
Common Medications in Children

Brand Name
4:52 PM
(Generic Name) Indications Common Side Effects Cautions

• Adderall, Adderall Stimulant used to Abdominal pain, vomiting, Do not use with heart
XR (amphetamine- improve attention, weight loss, decreased disease, HTN, hyper-
dextroamphetamine) decrease symptoms appetite, HA, insomnia, thyroidism, glaucoma,
of ADHD, approved nasal congestion, irritability; anxiety/tension/agitation,
for children >3 yr, may increase BP Tourette syndrome, hx of
3/11/10
long-acting form drug abuse, hx of seizures,

works 8–12 hr taking MAOIs; with skin
184
patch could cause irritation
at application site
MEDS
• Advair (fluticasone) Corticosteroid and URT infections, throat Recent exposure to

1815_Tab05_184-197.qxd
[breath-activated; bronchodilator; irritation, ENT infections, chickenpox, DM, heart

may be difficult for used for nosebleeds, sinusitis, HA, disease, HTN, infection,
young children] maintenance of GI discomfort and pain, liver disease, immune
asthma signs and N & V, candidiasis of the system disorders, overactive
symptoms; for mouth or throat, fever, thyroid, seizure disorder,
frequent asthma chest symptoms allergic reaction to steroids
symptoms, attacks,
and use of rescue
medicines
Page 185
Brand Name
• Allegra Antihistamine, for Colds or flu, coughing, HTN, diabetes, heart
(fexofenadine seasonal allergic drowsiness, fatigue, fever, disease, increased ocular
hydrochloride) rhinitis/hay fever, HA, indigestion, menstrual pressure, prostate
4:52 PM
[tablets and oral for children >6 yr problems, nausea, pain problems, hyperthyroidism;
suspension] old including back or ear pain should not combine with
erythromycin or
ketoconazole; do not use
within 2 wk of taking MAOI
3/11/10
• Amoxil (amoxicillin; Antibiotic; used for N & V, diarrhea, Liver and kidney disease,
MEDS
capsules) [chewables, bacterial infections pseudomembranous asthma, bleeding disorder,
oral suspension] including otitis colitis, tooth discoloration, mononucleosis; do not use
185
media, UTI, hepatitis, crystalluria, if allergic to penicillin

pneumonia, E. coli anemia, reversible
hyperactivity, agitation,
1815_Tab05_184-197.qxd
anxiety, insomnia,
confusion, convulsions,
behavioral changes,
dizziness
• Ativan (lorazepam) Benzodiazepine, Dizziness, sleepiness, Caution with hx of
used in manage- weakness, feeling depression or thoughts of
ment of anxiety unsteady, N & V, visual suicide; hx of liver, kidney,
and in seizure/ disturbance, insomnia, or respiratory dysfunction;
epilepsy forgetfulness, change in hx of alcohol abuse
appetite, skin rash
Page 186
Brand Name
• Augmentin Antibiotic; for Mild diarrhea, gas, Liver and kidney disease,
(amoxicillin and bacterial infections stomach pain, N & V, HA, asthma, mononucleosis;
clavulanate including sinusitis, skin rash or itching, white call HCP with severe
potassium) pneumonia, ear patches in mouth or diarrhea or diarrhea that
4:52 PM
infections, bronchitis, throat, yeast infection lasts >3 days, nausea,

UTI, skin infections stomach pain, low fever,
loss of appetite, dark
urine, clay-colored stools,
jaundice
3/11/10
• Botox (botulinum Blocks HA, dizziness or Seek immediate attention

MEDS
toxin A) [injection] neurotransmitter drowsiness, soreness with allergic reaction,
186
transmission, at injection site, nausea difficulty breathing, talking,
inhibits acetyl- swallowing, unusual or
choline; reduces excessive weakness, chest
spasticity by pain, irregular heartbeat
1815_Tab05_184-197.qxd
temporary
weakening of
muscle
• Claritin (loratadine) Antihistamine for HA, nervousness, Liver or kidney disease,
[OTC chewables and seasonal allergic drowsiness, stomach pain, PKU; call HCP with fast
syrup]/Clarinex rhinitis/hay fever; diarrhea, dry mouth, sore or irregular heart rate,
(desloratadine, for children >6 yr throat, hoarseness, eye feelings of syncope,
isomer form) [Rx old redness, blurred vision, jaundice, seizures
only, for children nosebleed, skin rash
>12 yr]
Page 187
Brand Name
• Cipro (ciprofloxacin) Antibiotic N & V, dizziness or Kidney disease, joint
(fluoroquinolone); drowsiness, blurred problems, seizure disorder;
for bacterial vision, insomnia, joint do not take with milk,
4:52 PM
infections stiffness or muscle pain, yogurt, or calcium-fortified

increased sensitivity of juices; call HCP with
skin to sunlight seizure, hallucination/
confusion, sudden pain/
joint swelling, nausea,
stomach pain, low fever,
3/11/10
MEDS
loss of appetite, dark urine,
clay-colored stools,
187
jaundice, watery/bloody
diarrhea, decreased
urination, numbness or
1815_Tab05_184-197.qxd
tingling, chest pain or

irregular heartbeat
• Concerta Stimulant; used to Abdominal pain, vomiting, Do not use with heart
(methylphenidate) improve attention, weight loss, decreased disease, HTN, hyperthy-
[long-acting] decrease symptoms appetite, HA, insomnia, roidism, glaucoma,
of ADHD nasal congestion, anxiety/ tension/ agitation,
irritability; may increase Tourette syndrome, hx of
BP drug abuse, hx of seizures,
taking MAOIs; with skin
patch could cause irritation
at application site
Page 188
Brand Name
• Enbrel (etanercept) Disease-modifying HA, sinus infection Suppressed immune
[injection] antirheumatic, for system, bone marrow
4:52 PM
symptoms of severe disease, seizures, diabetes,

arthritis/JRA increased risk of infection;
call HCP with allergic
reaction, muscle pain,
weakness, visual
disturbance, seizure,
3/11/10
MEDS
depression, symptoms of
TB (persistent dry cough,
188
weight loss, fever, night
sweats)
• Dantrium Muscle relaxant, Drowsiness, dizziness, Liver, heart, or lung
1815_Tab05_184-197.qxd
(dantrolene sodium) reduction of fatigue or weakness, disease; call HCP with

[capsules and spasticity, for diarrhea, blurred or allergic reaction, rash
injection] children >5 yr old abnormal vision, or itching, black, bloody,
constipation, upset or tarry stools or severe
stomach, decreased diarrhea, yellow skin or
appetite, difficulty eyes, seizures
swallowing, HA, insomnia,
depression/confusion,
increased urination
Page 189
Brand Name
• Daytrana Stimulant, used to Vision problems; mild skin Not within 2 wk of taking
(methylphenidate) improve attention, redness, bumps, or itching; MAOI, or if have (or positive
[skin patch] decrease symptoms N & V; loss of appetite; family hx) glaucoma,
4:52 PM
of ADHD weight loss; insomnia; Tourette syndrome,

stuffy nose; sore throat depression, severe anxiety;
hx of skin reaction to
transdermal patches, hx
of congenital heart defects,
HTN, heart failure, seizure
3/11/10
disorder, hx of substance
MEDS
addiction; call HCP with
189
severe HA with fever,

weakness, or pain, change
in heartbeat, usual
behaviors
1815_Tab05_184-197.qxd
• Depakene (valproic Anticonvulsant, Dizziness, sleepiness or Should not be used in

acid) used in insomnia, HA, diarrhea or children <2 yr old, risk of
management of constipation, stomach liver and pancreatic
seizure/epilepsy upset, vomiting, change in problems
appetite, weight gain
• Depakote Used in manage- Sleepiness, weakness, Do not take with liver
(divalproex sodium) ment of seizure/ depression, weight change, disease, caution with
epilepsy, bipolar visual disturbance, upset blood disorders, HIV or
disorder, prevention stomach, diarrhea or CMV, hx of head injury or
of migraine constipation, change in coma
menstrual period
Page 190
Brand Name
• Dilantin (phenytoin) Anticonvulsant, Dizziness, insomnia, HA,, Caution with hx of
used in manage- N & V, joint pain, skin diabetes, porphyria,
ment of seizure/ rash/itching vitamin D deficiency,
4:52 PM
epilepsy liver disease

• Lioresal (oral Activates inhibitory Back pain, constipation, Seek immediate attention
baclofen) GABA type B diarrhea, dizziness, with severe allergic
receptors, for drowsiness, fatigue, HA, reactions, agitation, chills,
management of increased breathing, inability to urinate, loss of
spasticity increased salivation, muscle tone, seizures
3/11/10
MEDS
itching, muscle weakness,

nausea, problems urinating
190
• Lioresal (intrathecal Management of Loose muscles, sleepiness, Overdose: Drowsy,
baclofen [ITB]) severe spasticity; upset stomach, vomiting, lightheaded, respiratory
may first have to HA, and dizziness; pump depression, seizures,
1815_Tab05_184-197.qxd
fail oral baclofen to failure could cause LOC, coma; underdose:

try ITB overdosing/underdosing increase/return in
spasticity, itching, low BP,
lightheaded, tingling
• Luminal Barbiturate (CNS Dizziness, sleepiness, HA, May interact with other
(phenobarbital) depressant), used N & V, feeling unsteady, meds including valproic
in management agitation, low blood acid, beta blockers,
of anxiety and in pressure, slowed corticosteroids—altering
seizure/epilepsy heartbeat and breathing their effects
(typically in
emergent situations)
Page 191
Brand Name
• Neurontin Anticonvulsant, Dizziness, sleepiness, Used for epilepsy only in
(gabapentin) used in manage- N & V, diarrhea or children >12 yr, for partial
4:52 PM
ment of seizure/ constipation, dry mouth, seizures in children 3–12 yr;

epilepsy sore throat, HA, visual use with caution with
disturbance, skin rash, heart, liver, or kidney
insomnia; call HCP disease
changes in memory,
focus, behaviors
3/11/10
MEDS
• Prednicen-M Steroid, commonly Weakness, osteoporosis, Kidney or liver disease,
(prednisone) used in acute fracture, Cushing’s thyroid disorder, diabetes,
191
asthma, JIA, syndrome, pituitary- TB, HTN, CHF, stomach

allergic reactions, adrenal axis suppression, ulcer, ulcerative colitis,
acute leukemia, growth suppression, diverticulitis, depression,
1815_Tab05_184-197.qxd
and other glucose intolerance, mental illness; call HCP

conditions acne, edema, HTN, with allergic reaction,
hypokalemia, alkalosis, swelling, SOB, visual
cataracts, glaucoma, disturbance, bloody/
peptic ulcer, N & V, tarry stools, severe
HA, vertigo, seizures, stomach pain, N & V,
psychoses, pseudotumor signs/symptoms of low
cerebri, skin atrophy, potassium or of severe
mood swings, irritability, HTN
insomnia
Page 192
Brand Name
• Proventil (albuterol) Relief of acute Anxiety, nervousness, Heart condition, seizure
bronchospasm, trembling, cough, diarrhea, disorder, HTN, abnormal
used in manage- difficulty sleeping, dry heartbeat, overactive
4:52 PM
ment of asthma mouth, mild HA, nasal thyroid gland, diabetes;

congestion, runny nose, call HCP if severe allergic
nausea, upset stomach, reaction on first dose or if
throat irritation (mild), notice change in heartbeat
unusual taste at any time
• Rheumatrex Slow-acting N & V, upset stomach, Do not use if have liver
3/11/10
(methotrexate) antirheumatic, for dizziness, fatigue, HA, disease or a blood or

MEDS
cancer and severe bleeding of gums, blurred bone marrow disorder; call
192
arthritis/JRA vision HCP with dry cough, SOB,
diarrhea, vomiting, white
patches or sores inside
mouth or on lips, blood in
1815_Tab05_184-197.qxd
urine or stools, decreased

urination, fever, chills,
body aches, flu symptoms,
sore throat and HA with a
severe blistering, peeling,
and red skin rash, pale skin,
easy bruising or bleeding,
weakness, nausea, stomach
pain, low fever, loss of
appetite, dark urine, clay-
colored stools, jaundice
Page 193
Brand Name
• Risperdal Antipsychotic, Drowsiness, constipation, Call HCP with fever,
(risperidone) for symptomatic fatigue, weight gain; less muscle stiffness,
4:52 PM
treatment of common but serious side confusion, sweating,

irritability in autism, effects include neuroleptic irregular heartbeat, tremor,
also used in ADHD, malignant syndrome, trouble swallowing or
for children 5–16 yr tardive dyskinesia, other signs of allergic
old hyperglycemia and reaction, lightheaded,
diabetes fainting
3/11/10
MEDS
• Ritalin, Ritalin SR, Stimulant; used to Vision problems, mild skin Congenital heart conditions,
Ritalin LA improve attention, rash, dizziness, nervous HTN, family hx of mental
193
(methylphenidate) decrease symptoms feeling, insomnia, N & V, illness, seizure disorder,

of ADHD loss of appetite, weight hx of substance addiction;
loss call HCP with irregular
heartbeat, lightheaded,
1815_Tab05_184-197.qxd
HTN, fever, sore throat,

skin rash or easy bruising,
unusual behavior
• Singulair Leukotriene Upset stomach, nausea, Call HCP with skin rash,
(montelukast) [oral receptor diarrhea, mouth pain, bruising, severe tingling,
granules and antagonist, used for fatigue, dizziness, HA, numbness, pain, muscle
chewables] seasonal allergies, sore throat, cough, weakness, severe sinus
asthma; approved hoarseness, nasal pain, swelling, or irritation,
for >1 yr old congestion worsening of asthma
symptoms
Page 194
Brand Name
• Straterra Nonstimulant; Similar to stimulants, FDA warning of increased
(atomoxetine) inhibits presynaptic including poor appetite, suicidal thinking in children
norepinephrine nausea, vomiting, and adolescents, caution if
4:52 PM
transporter; tiredness, upset stomach given with IV albuterol, do

improves attention, not use with heart disease,
hyperactivity/ HTN, tachycardia
impulsivity in ADHD
• Tamiflu [tablets and Antiviral, Vomiting, abdominal pain, Effective for types A and B
3/11/10
oral suspension] neuraminidase nosebleeds, ear disorders, flu

MEDS
inhibitor; conjunctivitis
management of flu;
194
must start first 1–2
days of symptoms
• Tegretol Anticonvulsant, Dizziness, sleepiness, HA, Do not take with hx of
1815_Tab05_184-197.qxd
(carbamazepine) used in manage- feeling unsteady, upset bone marrow

ment of seizure/ stomach, visual suppression, allergies to
epilepsy disturbance antidepressants, not within
2 wk of taking MAOI
• Topamax Anticonvulsant, Dizziness, sleepiness, HA, Do not use in children
(topiramate) used in feeling unsteady, insomnia, <2 yr; caution with liver,
management of loss of appetite, weight kidney disease, respiratory
seizure/epilepsy; loss, numbness/tingling, dysfunction, glaucoma
also used to changes in memory,
prevent migraine focus, speech
Page 195
Brand Name
• Valium (diazepam) Benzodiazepine, Drowsy, tired, blurred Liver or kidney disease,
used in manage- vision, insomnia, muscle respiratory disease,
4:52 PM
ment of spasticity, weakness, lack of balance glaucoma, seizure disorder,

also used with or coordination, slurred hx of depression, suicidal
seizure/epilepsy speech, N & V, thoughts or substance
constipation, HA, addiction; call HCP with
drooling, skin rash unusual behaviors,
3/11/10
depression, hyperactivity
MEDS
or agitation, hallucinations,
fainting, tremor, fever
195
and flulike symptoms,

jaundice, decrease in
urination
1815_Tab05_184-197.qxd
• Vantin Cephalosporin, for Mild nausea, vomiting, Call HCP with watery/
(cefpodoxime) bacterial infections stomach pain, bloating, bloody diarrhea, SOB,
gas, headache, fatigue, swelling, rapid weight
back pain, muscle pain, gain, irregular heartbeat,
insomnia, anxiety, seizure, warmth, redness,
nervousness, spinning numbness or tingling,
feeling, decreased taste fever, sore throat, HA
sensation, increased or with severe blistering,
decreased urination peeling, red skin rash
Page 196
Brand Name
• Vyvanse Stimulant, to N & V, stomach pain, loss Heart disease, heart failure,
(lisdexamfetamine) improve attention, of appetite, weight loss, congenital heart defect,
[once-daily/ decrease symptoms blurred vision, skin rash, HTN, thyroid disorder,
4:52 PM
long-acting] of ADHD, less likely feeling irritable, insomnia, glaucoma, severe anxiety,
to be abused dry mouth, unpleasant history of substance
because it must be taste addiction or mental illness,
digested before it Tourette syndrome; call
becomes active HCP with irregular
heartbeat, changes in
3/11/10
blood pressure, tremor,

MEDS
unusual behaviors
196
• Xopenex Bronchodilator, Anxiety, nervousness, Heart disease, HTN,
(levalbuterol) relief of acute trembling, cough, diarrhea, hyperthyroid, seizure
[inhaled by mouth] bronchospasm difficulty sleeping, dry disorder, diabetes; call
mouth, mild HA, nasal HCP with severe allergic
1815_Tab05_184-197.qxd
congestion, runny nose, reaction, worsening of

nausea, upset stomach, respiratory symptoms,
throat irritation (mild), chest pain or irregular
unusual taste heartbeat
• Ziana (clindamycin Combination of Erythema, scaling, itching, Do not use with regional
and tretinoin an antibiotic and burning, stinging; may enteritis, ulcerative colitis,
combination) tretinoin, for acne cause temporary change or history of antibiotic
[topical gel] in children >12 yr in skin color; in rare associated colitis
old instances can cause
colitis, with severe watery
or bloody diarrhea
Page 197
Brand Name
• Zanaflex Short-acting muscle Drowsiness or dizziness, Liver or kidney disease, high
(tizanidine) relaxant; used in anxiety or nervousness, or low BP, hx of long Q-T
spasticity numbness or tingling, syndrome; call HCP with
4:52 PM
management stomach pain, diarrhea, lightheadedness, slow

constipation, vomiting, heartbeat, hallucinations or
fever, dry mouth, muscle confusion, nausea, stomach
weakness, back pain, pain, low fever, loss of
increased muscle appetite, dark urine, clay-
tone/spasms, sweating, colored stools, jaundice,
3/11/10
skin rash pain with urination
MEDS
• Zithromax Macrolide antibiotic, Mild N & V, diarrhea, Liver or kidney disease,
197
(azithromycin) for bacterial constipation, stomach heart rhythm disorder, hx

infections pain, dizziness, fatigue, of long Q-T syndrome; call
HA, vaginal itching or HCP with watery or blood
discharge, mild itching diarrhea, chest pain,
1815_Tab05_184-197.qxd
or skin rash irregular heartbeat, nausea,

stomach pain, low fever, loss
of appetite, dark urine, clay-
colored stools, jaundice
• Zyrtec (cetirizine) Antihistamine, for Dizzy, drowsy, fatigue, Call HCP with irregular
[OTC chewables seasonal allergic dry mouth, sore throat, heartbeat, weakness or
and syrup]/Xyzal rhinitis/hay fever in cough, nausea, tremors, insomnia,
(levocetirizine children >2 yr old; constipation, HA hyperactivity, confusion,
dihydrochloride) chronic idiopathic visual disturbance,
[isomer form urticaria/hives in decreased urination
Rx only] children >6 mo old
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INTERVEN
Key Principles in Service Delivery

Developmentally Appropriate Care
■ Provide support
■ Exhibit patience
■ Have reasonable developmental/age-appropriate expectations
■ Use slow, simple instructions
■ Break down tasks into smaller steps when needed
■ Assist child in focus and attention on instructions
■ Provide consistency and structure
■ Provide choices, when possible
■ Give time to practice and for information processing
■ Promote socialization with other children/siblings
■ Incorporate therapy activities into daily routines
Family-Centered Care
■ Remember professionals come and go, family are constant
■ Support family/professionals—collaboration throughout continuum
of care
■ Honor family traditions and diversity
■ Acknowledge family strengths and methods of coping
■ Recognize developmental needs of child and family
■ Consider emotional and financial support needs of child and family
■ Create flexible, culturally sensitive, family-responsive care systems
Culturally Competent/Sensitive Care

■ Recognize culture-identified definitions of “family”
■ Appreciate that family choices may be based in cultural traditions
■ Integrate cultural knowledge into facility policies and procedures
■ Work within and use the support of community helping networks
■ Design and implement services to meet the unique needs of individuals
and families
■ Direct service by culturally preferred choices, not culturally blind or
culturally free interventions
■ Seek to provide equal and nondiscriminatory access to services
198
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199
Using Natural Environments
■ Provide services in settings that are familiar to the child/family and
represent the places where they carry out their routine daily activities
(home, child care centers and preschools, playgrounds, libraries,
shopping centers, restaurants)
■ Incorporate the people and things that are a part of the child’s natural
environment (siblings, grandparents, neighbors, etc.)
■ Provide practice with a focus on function and socialization
Communicating With Children

■ Allow time for the child to feel comfortable; take a position at the
child’s eye level, and speak in a quiet, confident voice
■ Avoid actions the child may perceive as threatening (e.g., sudden
advances, extended eye contact)
■ Try communicating through the parent/caregiver or through transition
objects (dolls, puppets, stuffed animals) with shy or withdrawn children
■ Use simple words; short sentences; and clear, specific, positively
oriented directions and suggestions
■ Be honest and encourage expression of concerns and fears
■ Provide opportunities for older children to talk when parents are not
present, when appropriate
Consultation/Collaboration
■ Steps in the process
■ Identify and clarify problem
■ Consider alternative solutions
■ Select, implement, and monitor solutions
■ Evaluate solutions
■ Collaborative consultation—process by which regular and special
education teachers or teachers and specialists work toward common
goals with shared responsibilities
■ Methods for including consultation on IFSP or IEP
■ Consult with child at specified time
■ Consult with teacher/family at specified time
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■ Consult as a support to direct intervention

■ Consult listed as an objective/benchmark to support a specific
IEP goal
■ Consult listed in the “specially designed instructions” section or as
an aid/support to personnel
200
Page 201
Special Intervention Considerations

for Children and Adolescents—Key:
Indications—Contraindications—Take Precaution
12:34 PM
Thermal Modalities (* relative contraindication)

Heat Cold Whirlpool/Hydro/Aquatics Ultrasound/Phono.
• Decreased ROM • Pain, acute injury • Decreased circulation • Pain
INTERVEN
• Subacute injury • Spasticity • Tactile hypersensitivity • Swelling
• Acute inflammation • Cold hypersensitivity • After cast removal • Scar tissue
• Acute bleeding • Cryoglobulinemia • Decreased ROM • Adhesions
3/12/10
• Fever • Arterial insufficiency • Joint unloading *• Tuberculosis

• Malignancy* • Thermoregulation • Avoid full immersion • Pregnancy
• Thermoregulation problems* in young children • Over epiphyseal
201
problems* • Absent sensation* because of poor ther- plate*

• Absent sensation* moregulatory ability • Malignancy*:M
)
*
n
(
o
i
s
t
e
a
c
i
d
l
n
ao
r
t
M
n
l
c
a
e
i
v
n
a=
t
h
c
l
e
2
r
Mechanical Modalities (*relative contraindication)
1815_Tab06_198-238.qxd
Traction Compression Estim/TENS

• Pain or spinal impingement • Peripheral edema • Decreased strength
that is relieved with traction • Infection • Spasticity
• Spinal infection, cancer, • Thrombi • Pain, swelling
tumors • Cancer • Muscle reeducation
• RA • Unstable fracture • Pacemaker, over
• Osteophytes*, osteoporosis* • Arterial insufficiency heart
• Joint hypermobility* • Cellulitis • Area of thrombi
Continued
Page 202
Traction Compression Estim/TENS

• Pregnancy* • Pregnancy
• Traction anxiety* • Tuberculosis
• No chin strap with TMJ • Cancer*
dysfunction
12:34 PM
INTERVEN
Manual Therapy
M
m
yp
MPeripheral
areh
T Joint Mobilization Massage Myofascial Release
•Decreased ROM • Decreased circulation • Decreased ROM
3/12/10
•Joint capsule restriction • Tactile hypersensitivity • Fascial or soft tissue

•Osteoporosis • Premature infants (GI, wt restriction
gain, bonding)
202
•Joint inflammation • Systematic or localized
•Mobilization > grade III • Infection infection
• Abnormal body • Open wounds
temperature • Healing fractures
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• Influenza • Acute inflammation

• Severe upper respiratory • Cancer
infection • Osteoporosis
• Tuberculosis • Hypotonia
• Developmental dysplasia
of hip
• Wounds
• Acute illness
Continued
Page 203
12:34 PM
INTERVEN
Therapeutic Exercise
Strengthening Aerobic Activities
3/12/10
• Decreased strength and/or fitness • Decreased fitness

• Training for athletic participation • Training for athletic participation
• No power lifting, bodybuilding, maximal • Medical screening before exercise with
203
lifts before skeletal maturity hx of cardiorespiratory dysfunction,

• Medical screening before exercise with hx rheumatic fever
of cardiomyopathy, pulmonary artery • Avoid prolonged aerobic activity in hot
1815_Tab06_198-238.qxd
hypertension, Marfan’s syndrome weather

• Uncontrolled hypertension, seizure • Caution with allergy and exercise-induced
disorders, hx of cancer or chemotherapy asthma, type I and II diabetes
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INTERVEN
Positive Behavior Supports

Behavioral Analysis—Evaluation and Documentation
■ Identify and define challenging behavior(s), including precipitating
situations or behaviors
■ Determine child’s normal routines and when challenging behaviors
are likely to occur
■ Investigate rationale for defining behavior as problematic; identify
potential reasons for child’s behaviors (e.g., many children “act out”
to avoid difficult situations)
■ Determine child’s strengths, needs, likes, dislikes; family/cultural
values/norms; physical or environmental factors assoc. with behavior
■ Obtain objective baseline of child’s challenging behaviors so strate-
gies can be measured for effectiveness
■ Develop plan of action, frequency, and methods for documenting strate-
gies and outcomes with family/caregiver (and child if appropriate)
General Principles and Strategies

■ Set firm, clear, agreed-on limits on the child’s behavior; parents/
caregivers are your partners in behavior supports
■ Be fair; follow through with own instructions, agreements, and con-
tracts (if/then)—if you say “this is the last one,” be true to your word;
when possible, involve the child in making choices
■ Consider age-appropriate and developmentally appropriate expecta-
tions that take child’s difficulties into account
■ Communicate in simple language with short one- or two-step direc-
tions; tell the child what you want him or her to do, not what you
don’t want him or her to do (e.g., Please walk vs. Don’t run)
■ Provide specific praise for positive behaviors; do not say “good job”
if the child was not on target
■ Respond to inappropriate behaviors immediately; respond in timely
fashion to appropriate behaviors as well—make it clear to the child
what he or she has done well and what he or she has not done well
■ Apply consistent, logical consequences to behaviors; use natural con-
sequences when safe and appropriate
204
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205
■ Stay with one strategy for a time to allow for effectiveness; when
using positive behavior supports, child’s behavior may get worse
before it gets better
■ Incorporate tangible reward systems (e.g., stickers, food treat, small
prize); use rewards that are appealing, make program fun, involve
child in decision making, gradually increase expectations to achieve a
reward, and eventually replace tangible rewards with praise
Examples—Specific Strategies and Definitions

■ Planned ignoring—withhold attention in response to inappropriate
behavior; effective with minor issues where safety is not an issue
■ Response-cost—loss of a privilege in response to inappropriate
behavior; do not threaten child, make clear the consequence; do not
use a privilege that you do not have the right to withhold
■ If-then contracting—can be child or adult directed, if an adult desired
behavior is carried out, it will be rewarded with something meaning-
ful and desirable to the child (e.g., “If we throw the ball 10 times, then
we can play with the puzzle for 2 minutes”)
■ Quiet time—child is moved away from the activity or situation and
asked to sit quietly for a defined period
■ Time-out—child is removed from the situation and not given any pos-
itive attention or reinforcement for a defined period; more effective
for older children who understand the consequences of their actions
Tips for Decreasing Frustration in Learning Novel Tasks
■ Be consistent—early on when learning something new, keep the con-
text and environment the same, then as skill develops, practice in
other situations and conditions
■ Use repetition—allow child to practice new skill for many trials over
several days or if needed several weeks before making changes in
the task
■ Provide simple, short instructions and directions—use one- and two-
step directions and avoid complex or excessive verbal instructions,
use visual and physical demonstrations where possible
■ Let the child take the lead—give limited choices, encourage inde-
pendence, and go at the child’s pace; consider child’s readiness to
learn
INTERVEN
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INTERVEN
■ Give praise and celebrate early successes—praise child’s efforts while

giving accurate feedback on performance, focus on the elements that
child performs correctly so they become consistent, and work with
child to alter elements that need to be improved
■ Balance assistance and independence—have realistic expectations,
but also allow child to make and learn from mistakes (within the con-
founds of safety); provide only the assistance and feedback needed to
create success—have the child do as much as he or she can; the child
should be an active participant in the entire process
206
Page 207
Goal Setting and Documenting Interventions

Characteristics of Well-Written Goals and Objectives for School Settings (from Dole et al, 2003)
Measurability Educational Relevance Overall Quality/Compliance
• Use an identified method for • Enhance school function or • Be well defined, specific,
12:34 PM
measuring achievement child’s ability in school clear, and without jargon

• Describe an observable behavior • Be easily understood by all • Relate to functional/
INTERVEN
or functional skill those involved educational skill
• Use valid and acceptable • Relate directly to school/ • Be realistic and achievable
measurement strategies/tools classroom curriculum or within time frame specified
• Specify level or amount of goals/requirements • Relate to long-term goal
3/12/10
assistance or cueing needed • Assist in gaining benefit • Be child focused

• Be able to be measured reliably from educational setting/ • Be meaningful to all those
207
by others besides therapists placement involved

• Identify specific, quantitative • Relate to achievement of • Include an action verb
criteria for achievement IEP goals
• Be associated with a
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general school activity

Considerations for Functional Goal Setting in All Pediatric Settings
• Identify skills or behaviors for change/improvement—consult with child, family, caregivers, teachers, etc.
• Relate to child’s ability to learn, function at school/home, participate in social roles
• Consider how skill can be observed/documented in a measurable way; clear and meaningful to all
involved
• Determine and document baseline skill performance based on observable and measurable criterion
• Describe what skill would look like if/when it improves; how would you know?
• Describe what is needed to allow this change and what is child’s general rate of learning/prognosis
for achieving new level of performance
Page 208
Quick Documentation Tips for Specific Pediatric Settings

For Medical Settings For Early Intervention Settings For Educational Settings
• Medical and profession jargon • Uses family-friendly, lay • Avoid professional jargon;
often used; person-first language language; "child" vs. "child/student" vs. "patient"
is preferred "patient" or "client" or "client"
12:34 PM
• Comply with setting's policies • Meet requirements of IDEA • Meet requirements of IDEA
in use of abbreviations for IFSPs for IEPs
INTERVEN
• Goal setting is usually discipline- • Goal setting in collabora- • Goal setting in collaboration
specific and should be done in tion with family and service with education and support
consultation with child and family team service team and child and
family
3/12/10
• Must justify need for skilled care • Should discuss efforts to • Show connection of interven-
and medically necessary deliver care in natural tion and strategies to child's
208
interventions environments school participation
• Re-examine as frequently as • Re-examine every 6 mo • Re-examine every 3 yr mini-
needed and to comply with minimum mum; update IEP yearly
1815_Tab06_198-238.qxd
setting and reimbursement

provider policies
• Documentation of every • May use state- or county- • Daily documentation may not
intervention session required, based forms for each visit be required by school system;
often shared with other or daily encounter state practice acts may have
health-care practitioners and such requirements
third-party payers • Periodic reporting/report cards
to address progress toward IEP
• Formal discharge documentation • Formal discharge documen- • Team makes discharge deci-
often required, hand-off tation may not be required sions; check state practice act
communication recommended by setting, check state for discharge documentation
practice act requirement requirement
Page 209
Intervention Approaches—Aquatic Therapy

Theoretical Foundation
12:34 PM
• Water buoyancy may aid in postural support, decrease effects of gravity on movement, and unload
joint structures
• Water temperature may have an effect on muscle extensibility and ease of movement
INTERVEN
• Exercise in water may promote overall cardiorespiratory fitness
• It is debated on whether functional activities practiced in water can translate to improved perfor-
mance on land
3/12/10
Basic Principles and Application

• Water can be used to assist or resist movement for ROM and strengthening exercises
209
• Aerobic and anaerobic exercise can be performed in water

• Intervention can be provided individually or in a group
• Aquatic intervention is often combined with traditional land-based therapy
1815_Tab06_198-238.qxd
Intended Populations Evidence

• Children and adults with deficits in flexibility, • Systematic review (Getz et al, 2006) of
strength, movement, and function 11 articles (including one RCT); aquatic
• Special populations for which exercise in other interventions for children with neuromotor
environments would be restricted (e.g., juvenile impairments; statistical evidence for
rheumatoid arthritis/juvenile idiopathic arthritis, improvements in respiratory function in
osteogenesis imperfecta, muscular dystrophy) children with CP; other evidence to support
improvements in gait and motor skills were
noted, but strength of evidence to support
these improvements is low
Page 210
Intervention Approaches—Cognitive Orientation to Daily

Occupational Performance (CO-OP)
12:34 PM
• Cognitive approach to achievement of daily occupational skills
INTERVEN
• Based in cognitive psychology and cognitive theories of learning (e.g., Vygotsky, Luria)
• Uses problem-solving strategy (goal-plan-do-check) derived from Meichenbaum (1977) & Camp et al
(1976)
3/12/10
• Six key features: “session structure, child-chosen goals, dynamic performance analysis, cognitive
strategies, enabling principles and parent/caregiver involvement” (Polatajko et al, 2001; p. 112)
210
• Global problem-solving framework
• Importance of transferring and generalizing skills to daily life
• Encourages self-talk as child works through strategies
1815_Tab06_198-238.qxd
• Therapist as mediator to help guided discovery, acting as model and assisting in transfer of learning
to everyday life
• Children with developmental coordination • Pilot RCT (Miller et al, 2001); compared
disorder (DCD) and children with other CO-OP with non–problem-solving therapy
impairments of movement and coordination approach; 20 children who met criteria for
not explained by cognitive or major DCD; although both groups improved in
neurological insult self-ratings of performance and on
measures of motor skills, the CO-OP group’s
improvements were significantly greater
Page 211
Intervention Approaches—Conductive Education (CE)

12:34 PM
• Originated in 1940s in Hungary with Peto; has been adapted in its use in other countries
• Based on concept of “orthofunctioning personality”—actively learning to gain control over one’s
movement and function creates independence and self-assuredness; increased participation in
INTERVEN
society; and improved emotional and intellectual skills
• System of education, focuses on developing problem-solving skills
3/12/10
• Educational and rehabilitative goals are integrated into child’s program and all daily activities
• Curriculum development, planning, and delivery are accomplished by trained “conductors” who
211
address academic and rehabilitative goals

• Conductors provide guidance and encouragement, but usually do not provide physical assistance
• Traditionally CE is provided in socially supportive groups; activities are structured and tasks are
1815_Tab06_198-238.qxd
broken down into smaller achievable steps that children practice together
• Makes use of “rhythmical intention”—background songs/rhymes—that assists movement and
learning; may also employ specialized equipment (slatted beds and ladder-back chairs)
• Children and adults with physical or multiple • Systematic review (Darrah et al, 2004) of
disabilities resulting from damage to CNS 15 studies; revealed that the 20 statistically
significant results for the studies represent-
ing the strongest evidence were split evenly
(10 for the CE groups and 10 for the control
groups)
Page 212
Intervention Approaches—Constraint-Induced
Movement Therapy (CIMT)
12:34 PM
• Loss of unilateral upper extremity function after neurological insult may be due to developmental
INTERVEN
disuse/learned nonuse
• Repetitive movement practice and shaping with involved extremity may lead to improved use
through cortical reorganization
3/12/10

• Application of sling or other device to limit functional use of less involved upper extremity
212
• Engagement in specific functional tasks and activities with more involved upper extremity
• Intervention typically occurs in an intensive time frame (many hours per day/many days per week)
over a short duration (a few to several weeks)
1815_Tab06_198-238.qxd

• Individuals who have had a neurological insult • RCT by Charles et al (2006); used “child-
that results in upper extremity impairment (e.g., friendly” type of CIMT in 22 children with
stroke, hemiplegic CP) hemiplegic CP; CIMT group showed
improved scores in tests of fine motor func-
tion; improvements sustained for 6 mo;
authors note CIMT may be most beneficial
for children with moderate upper extremity
involvement who are able to attend well to
the intervention
Page 213
Intervention Approaches—Hippotherapy
12:34 PM
INTERVEN
• Three-dimensional movements of the horse elicit responses in the rider, facilitating adjustments
in posture, balance reactions, and movement and mimicking the weight shifting of the pelvis
during gait
3/12/10

• Alternating the rider’s position on the horse presents various balance challenges
213
• Therapists use techniques to encourage flexibility, strengthening, relaxation, attention to task, and
balance reactions
• Safety and support are ensured by having at least one “side walker” assisting the therapist and
horse working with the child
1815_Tab06_198-238.qxd

• Children and adults with CP or other dysfunction • Systematic review (Snider et al, 2007) of
of movement, balance, posture, or gait 10 studies; reasonable evidence of improve-
• Children and adults with attention deficits, ments in trunk and hip muscle symmetry
autism, sensory deficits/dysfunction, and and in overall gross motor function when
disorders of speech and language hippotherapy is compared with traditional
therapy or no therapy
Page 214
Intervention Approaches—Locomotor Training

(LT)/Body Weight Support Treadmill Training (BWSTT)
12:34 PM
• Plasticity of CNS, ability to regain walking skills after injury with the influence of training and practice
• Influencing a “central pattern generator” through specific sensory inputs to generate motor output
INTERVEN

• Training involves “task-specific” training in upright locomotion, typically on a treadmill with a
device that regulates body support and physical guidance to limbs to assist stepping
3/12/10
• Importance of hip extension in creating transition from stance to swing

• May be used in conjunction with neuromuscular stimulation
214
• Synchronization of loading/unloading of lower limbs on generation of stepping patterns
• Amount of body weight support, treadmill speed, and sensory inputs all can be varied to elicit
desired motor outcome
• Should also be done in conjunction with over-ground locomotor training/practice
1815_Tab06_198-238.qxd

• Children and adults with motor and sensory • Dodd & Foley (2007); matched-pairs controlled
impairments in walking as a result of neurological trial; 14 children (CP; GMFCS levels III and
dysfunction (e.g., CP, Down syndrome) or injury IV); statistically significant improvements in
(e.g., spinal cord injury, brain injury) self-selected walking speed in treadmill
group (2•/wk for 6 wk in school)
• 2 RCTs (Angulo-Barroso et al, 2008; Ulrich
et al, 2001); treadmill intervention in infants
with Down syndrome; included physical
activity and early onset of independent
walking
Page 215
Intervention Approaches—Motor Learning

• Based on neurophysiological, psychological, behavioral, and cognitive theories of the acquisition
of movement through practice
12:34 PM
• Rooted in understandings of task approach, information processing, closed loop, and open loop
theories of programming movement
• Application of Fitts & Posner’s (1967) stages of learning, Schmidt’s (1975) schema theory, Adam’s
INTERVEN
(1971) closed loop theory
• Makes critical distinction between performance and learning with respect to motor skills
3/12/10
• Importance of type of feedback (FB)—knowledge of performance (KP) vs. knowledge of results (KR)
• Scheduling of feedback frequency including relative, bandwidth, and time-delayed feedback
215
• Deliberate use of modeling and demonstration, prepractice instructions, and mental practice
• Key elements of practice include part to whole task practice, variability in practice, and contextual
variety in practice
1815_Tab06_198-238.qxd
• Transfer of training and generalizability to other tasks and contexts are crucial to learning
• Children and adults learning/relearning motor • Sullivan et al (2008) compared 100% and
skills/tasks (with or without impairments in reduced (62%) FB with a discrete arm task;
motor control) children used FB differently than young
adults
• Single system (Thorpe & Valvano, 2002);
KP alone vs. KP combined with cognitive
strategy; novel task performance; 13 children
with CP; all improved with practice; 8 of
13 showed significant difference with
augmented FB
Page 216
Intervention Approaches—Neurodevelopmental
Treatment Approach (NDT)
12:34 PM
• Originated with Bobath and Bobath in the 1940s

• Examination and intervention techniques rooted in reflex-hierarchical models of nervous system
INTERVEN
• Current practice adapted to reflect more current theories in neuroscience/systems models, motor
development, motor learning, and motor control
“Classic” NDT “Contemporary” NDT
3/12/10
• CNS dysfunction primary cause of dysfunction • Broader focus, with CNS as only one of
in movement, postural control, and development many systems that impact movement and
rigid focus on the normal developmental sequence development
216
• Decreased reliance on normal developmen-
tal sequence
1815_Tab06_198-238.qxd
“Classic” NDT “Contemporary” NDT

• Promote normal development through strict • Normal developmental sequence as a
adherence to normal developmental sequence general guide
• Decrease influence of altered muscle tone, • Focus on functional tasks and skills
primitive reflexes, abnormal movement patterns • Use of “key points of control”
• Use of “reflex-inhibiting” postures • Child is more active participant
• Child is relatively passive recipient of intervention • Address carryover to relevant settings and
• Elicit righting and equilibrium responses as situations
precursors of postural control
Continued
Page 217

• Originally developed for children with CP • Systematic review (Butler & Darrah, 2001)
• Also adults after stroke, children and adults of 21 studies from 1973–2000 (101 out-
12:34 PM
after acquired brain injury comes); 17 favoring NDT, 12 favoring

control, 72 no/nonsignificant change
INTERVEN
Intervention Approaches—Sensory Integrative Treatment (SIT)
3/12/10
217
• Based on the work of Ayres beginning in 1950s

• Relies on the premise that the brain processes sensory information (internal and external), organiz-
ing the information for a response
1815_Tab06_198-238.qxd
• Deficits in the ability to integrate sensory information for use (sensory processing disorder) can be
remediated with guided sensory inputs through a “just right challenge” to elicit an adaptive
response
• Individual intervention that encourages active participation that is child directed
• Therapist-guided sensory inputs (proprioceptive, tactile, vestibular) to elicit an adaptive response
• Address issues of understimulation or overstimulation of particular sensory systems
• Often administered through use of specific equipment (swings, balls, bolsters, trampolines, vibra-
tors, etc.) to provide experiences rich in proprioceptive, tactile, and vestibular input
• Aim is to improve underlying neurological function of sensory processing and organization
Continued
Page 218
12:34 PM
INTERVEN

3/12/10
• Children with sensory processing disorders • Meta-analysis (Vargus & Camilli, 1999) of
(SPD); includes sensory modulation, sensory 32 studies from 1972–1994; found positive
discrimination and sensory-based motor disorders results in earlier studies, which were of
218
• Children with learning disabilities, cognitive lesser methodological quality (SIT compared
impairment, attention deficits, motor with no intervention or other interventions),
incoordination/dyspraxia or other neurological whereas later studies showed no specific
1815_Tab06_198-238.qxd
dysfunction benefit of SIT compared with other

interventions
1815_Tab06_198-238.qxd 3/12/10 12:34 PM Page 219
219
Intervention Examples—Airway Clearance
General Principles
■ Uses positioning, turning, percussion, vibration, and cough to mobilize
bronchial secretions
■ May be used for short-term or long-term management of lung disease
(e.g., CF)
■ May be most effective in the morning or just before bed
■ Wait 1–2 hr after eating
■ Cough to expel sputum done after each postural drainage positioning
■ Use cupped hand or special device for percussion
■ Review special precautions related to position (e.g., ICP>20 mm Hg,
spinal sx/injury, hemorrhage, pulmonary edema), manipulation of
thorax (e.g., skin integrity issues, recent epidural or spinal anesthesia,
osteoporosis, rib fracture), and age (e.g., use only three fingers or
appropriately sized device for percussion in infants)
Techniques
■ Manual and mechanical methods can be used
■ Positioning uses effect of gravity to aid drainage
■ Percussion involves rhythmic cupping, clapping, and tapotement
■ Vibration involves tremor-like action of the hand
■ Deep breathing and productive coughing or huffing (less forceful cough)
■ Active cycle of breathing technique
■ Autogenic drainage
■ Types of airflow devices: oscillating positive expiratory pressure,
intrapulmonary percussive ventilation, positive expiratory pressure,
high-frequency chest wall oscillation vest
Positions for Postural Drainage

To view instructions and positions for use with infants and children,
see the Consumer Fact Sheet entitled “An Introduction to Postural
Drainage & Percussion” from the Cystic Fibrosis Foundation at:
http://www.cff.org/UploadedFiles/treatments/Therapies/Respiratory/
PosturalDrainage
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Intervention Examples—Balance/Posture
General Principles
■ Development of postural control proceeds primarily in cephalocaudal
fashion—muscular control at neck, then trunk, then lower limbs
■ ABCs of posture—alignment, base of support, center of mass
■ Alignment in static and dynamic sitting, standing, and lying positions
should preserve normal curvatures of spine and encourage symmetry
■ Influence of sensory systems on balance: Children rely primarily on
vision (<4 yr old), somatosensory (4–6 yr old), then vestibular inputs
(>7 yr old)
■ Consider body morphology, musculoskeletal and neuromuscular con-
straints on cone of stability
■ Impact of age, development/experience, and height on movement
strategies to control balance—ankle, hip, compensatory (flex hip,
knee, ankle to lower cog), stepping
■ Early standers and children with neurological impairment use proximal-
distal motor control strategies (hip strategy activated first); with expe-
rience, older children use more adult-like distal-proximal strategies
(ankle strategy activated first)
Techniques
■ Use activities that promote proactive (internal perturbation) and reac-
tive (external perturbation) strategies
■ Use movable/changing surfaces to challenge balance and encourage
movement/reach to edges and outside cone of stability
■ Promote alignment for efficient movement in all positions and func-
tional activities
■ Incorporate external supports to compensate when appropriate—
seating and positioning devices, taping, elastic body garments, etc.
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221
Examples of Strategies for Challenging Balance/Posture
Basic balance: Encompasses reach at limits of stability; transitional move-

ments, anticipatory postural strategies with games and play
Higher-level balance: Develop and practice skills in complex/challenging

environment; use novel tasks/situations that encompass problem-solving
and interaction with peers
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Intervention Examples—Electrical Stimulation

General Principles
■ Recruits muscle fibers opposite from that which occurs with volitional
concentric muscle contraction
■ Adjunct to therapy for improving strength and motor control, may
also be used to aid management of pain, edema, and spasticity
■ Facilitate timing of muscle contraction for functional activities (e.g., gait)
■ Safe in populations of children with and without neurological dysfunction
Techniques
■ Use to support isometric and isotonic strengthening programs
■ Common types include neuromuscular (NMES), threshold (TES),
transcutaneous (TENS)
■ Functional electrical stimulation (FES)—use of low-level current to
activate and coordinate muscle contractions (often after paralysis
owing to spinal cord injury) for functional skills
■ Has been combined with dynamic splinting to reduce/prevent
movement restriction/contracture
Guidelines for NMES in Children (from Carmick, 1997)

■ Electrode placement on muscle belly or motor point; standard size
electrodes may need to be cut to achieve desired results and avoid
stimulation of adjacent musculature
■ Waveforms may be symmetrical or asymmetrical—asymmetrical
waveforms may be more tolerable in children because of their smaller
muscle size
■ Set frequency and duty cycle parameters to minimize fatigue—even
10 min of practice of a skill with NMES can be tiring
■ Initial frequency can be set at 7 pulses per second (pps) for visible
contraction and correct selection of electrode placement (may need
to increase amplitude); when electrode placement is set, decrease
amplitude and set frequency at 30–35 pps; gradually increase ampli-
tude for desired effect
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223
■ Adjust amplitude to child’s tolerance and only while electrode is
active; amplitude may be increased with time and progress
■ Ramping should be 2–4 sec in duration when stimulation is first intro-
duced, then decreased to tolerance; note combining stimulation with
some functional skills (e.g., gait) requires very short onset times;
on-off times initially should be 5 sec on/20–25 sec off and increased in
10- to 15-sec increments; to avoid fatigue, use ratios of 1:5 or 1:6
Intervention Examples—Flexibility
General Principles
■ Always prepare muscles before stretching (heat, exercise, soft tissue
mobilization)
■ Increases in muscle extensibility occur best with low-load, long-duration
stretching
■ Hold static stretch for 15–30 sec for maximum effectiveness
■ Focus on gaining movement through entire ROM
■ Muscles that are overlengthened or overshortened have a decreased
ability to generate force
■ Muscles that cross and act across two joints need to be lengthened
across both joints
Techniques
■ Proprioceptive neuromuscular facilitation (PNF) (contract-relax,
hold-relax)
■ Deep tissue massage; other manual therapy techniques—strain-
counterstrain, positional release, MFR, etc.
■ Modalities—heat, cold
■ Neurofacilitation/inhibition
■ Medical management for spasticity (e.g., Botox, intrathecal baclofen)
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Examples of Different Strategies for Stretching

Use of External Supports/Splints
Ankle dorsiflexion: Knee flexion/extension:
Manual/Passive
Hip extension: Hip/knee flexion (hamstrings):
Continued
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225
Examples of Different Strategies
for Stretching—cont’d
Positional
Hip extension: Elbow extension:
Functional/Active
Ankle dorsiflexion: Lower back and hip/knee
flexion (hamstrings):
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Intervention Examples—Locomotion
General Principles
■ Locomotion—method of moving from one point to another; includes
rolling, creeping, walking, running, etc.
■ Consider developmentally appropriate means of locomotion/mobility
■ Consider three general functions of gait—stability, progression, adaptability
■ Consider context—constraints of time, variations in surface, environ-
mental demands/distractions, energy efficiency, safety
■ Address deficits in available movement/flexibility, efficiency of motor
control, attention to task, sensory systems (visual, vestibular,
somatosensory), rhythmicity
Techniques
■ Manual guidance and assistance for entire task or portions of task
■ Verbal guidance, instruction, feedback to enhance performance and
learning
■ External supports for balance and control (e.g., elastic strapping system,
taping)
■ Locomotion/mobility aids (e.g., canes/crutches/walkers/gait trainers, floor
mobility devices, wheeled mobility devices, adapted children’s toy cars)
■ Orthotic or prosthetic devices to aid upright balance and control
■ Muscle stimulation to facilitate generation, timing, and sustainability
of muscle contraction to support movement
■ Rhythmic stepping/cycling with treadmill, body weight support, or
cycling devices
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Examples of Strategies for Upright Locomotion/Gait
Stability: Use dynamic surfaces and challenges to develop postural

responses and pelvic control
Continued
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Examples of Strategies for Upright

Locomotion/Gait—cont’d
Progression: Assist weight shift and stepping with rhythmic action of the
treadmill
Adaptability: Practice in various contexts facing changing environmental

challenges
Use of supports: Use of assistive device/walking aid or orthotic devices to

enhance independence
228
Page 229
Locomotion/Gait Intervention Aims Based

on Prognosis for Community Ambulation
Best Prognosis General Aims of Intervention
• CP—GMFCS levels I & II; hemiplegia; most • Focus on functional contexts—home, school,
12:34 PM
with diplegia (~65% by 3 yr) community

• SB—lower lumbar and sacral lesions • Address compensations that could limit efficiency
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• DS—most by walk by 2–3 yr • Prevent long-term problems that may diminish
• SCI—incomplete lesions; >10 on Lower ambulation
Extremity Motor Scale (LEMS); grade 3–5 • Address various surfaces, elevations, and envi-
hip flexion and knee extension bilaterally ronments to create ability to adapt to changes in
3/12/10
• Cognitive impairment without neurological environment

dysfunction • Dual task strategies, use of UE for function
229
• Consider use of orthotic devices, if needed

Good to Guarded Prognosis General Aims of Intervention
• CP—GMFCS level III; diplegia (~20% with • Develop isometric strength of postural muscles
1815_Tab06_198-238.qxd
device); athetosis (most walk by 3 yr); ataxia in shortened ranges

(most walk by 8 yr) • Expand base of support with assistive devices or
• SB—high lumbar lesions orthotic devices
• SCI—incomplete lesions, >10 on LEMS; • Develop smooth progression and forward
grade 3–5 hip flexion or knee extension at propulsion
least one side • Address shock absorption, energy efficiency; UE
use for support
• Facilitate movement synergies in weight-bearing,
functional contexts
• Monitor alignment differences and overuse to
limit secondary complications
Continued
Page 230
12:34 PM
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Fair to Low Prognosis General Aims of Intervention

• CP—GMFCS level IV; spastic quadriplegia • Standing program for bone density, alignment,
3/12/10
(1⁄3 never walk, 1⁄3 with device, 1⁄3 without device) soft tissue strength
• SB—thoracic lesions • Trial with body weight–supported ambulation
230
• SCI—complete lesions (ASIA A) • Activities to generate rhythmical stepping
• Activities to develop control in upright positions
against gravity
• Alternative forms of mobility—manual or power
1815_Tab06_198-238.qxd
w/c, scooter, etc.

CP, cerebral palsy; DS, Down syndrome; SB, spina bifida; SCI, spinal cord injury.
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Intervention Examples—Motor
Control/Weakness
General Principles
■ American Academy of Pediatrics recommends warm-up and cooldown,
coupling strength training with aerobic/endurance training, durations
of at least 8 wk; 2–3⫻/wk with 2–3 sets of 8–10 reps/exercise; progres-
sion with weight in 10% increments only after 8–10 reps can be done
with correct technique
■ Children benefit from supervised strengthening exercises with correct
technique; relatively low resistance with relatively high reps; no
power lifting and weightlifting until physical and skeletal maturity
■ Address all muscle groups, exercise through the full ROM
■ Consider all variables that impact motor control (e.g., sensorimotor,
mechanical, cognitive, task-specific)
■ Consider all aspects of neuromuscular performance (e.g., force
production, power, endurance, timing, recruitment, synergistic
movement, selective control)
■ Although strength training/exercise is still controversial in some neu-
romuscular diseases (e.g. MD, SMA), preliminary evidence of benefits
in selected disorders exists
■ Exercise programs can include strength, flexibility, endurance, self-
esteem, and self-confidence in children with disabilities; strengthen-
ing shown to be safe, no increase in spasticity in children with CP
■ Difficult for children with disabilities to retain gains from fitness pro-
grams after completion, ongoing support for physical activity and
programs of longer durations (6 mo–1 yr) are needed
Techniques
■ Therapeutic exercise, progressive resistive exercise, strength training
(using resistance, body weight, elastic bands, functional activities)
■ Isometric, isotonic, isokinetic; concentric, eccentric; open-chain,
closed-chain
■ Incorporate developmentally appropriate strategies into play and
daily functional activities
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Examples of Incorporating Exercise in Play
Extremities: Climb, swing, push, pull, jump; engage major muscle groups
abd/back/core: Movable surfaces, reach, throw; prone vs. gravity
Intervention Examples—Motor Milestones

General Principles
■ Motor development occurs in predictable sequence, but range of typi-
cal can be wide
■ Motor development can be influenced by environment, experience,
and cultural practices
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233
■ Major motor milestones include those in the domains of oral motor,
fine motor, and gross motor skills
■ Maturation—measurable changes in physical growth, largely influenced
genetically and relatively resistant to external factors
Techniques
■ NDT and SIT approaches to sensorimotor development
■ Motor learning approaches
■ Cognitive and social learning approaches
■ Family education and support
■ Consideration of adaptive devices and equipment to support achieve-
ment of motor skills
■ Recognize interaction of other developmental domains—cognitive,
language, social-emotional
Examples of Ways to Encourage Motor Development
Oral Motor Skills: Promote age-appropriate motor/sensory exploration;

textures; encompassing motor control with functional daily activities
Continued
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Examples of Ways to Encourage

Motor Development—cont’d
Fine Motor Skills: Explore objects, textures; reach, grasp, manipulation;

use adaptive equipment to support function
Gross motor skills: Encompasses body awareness; exploration with

movement; transitions between positions; mobility and balance skills;
adaptations when needed
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Intervention Examples—Motor
Planning/Coordination
General Principles
■ Systems theory describes motor behaviors as emergent property
from interaction between individual, environment, and task—all three
are potential avenues for intervention
■ Movement proficiency on a continuum from stability to mobility to
controlled mobility to skill
■ Estimates indicate 5%–15% of all children (boys two-times > than
girls) have impairments of motor coordination and planning that are
not explained by a major neurological disorder; most also have atten-
tion deficits or learning disabilities
■ These problems are not typically “outgrown” as children age; social
and emotional impact can be significant in adolescent and adult years
■ Children with primary neuromuscular impairments can also exhibit a
range of motor planning and coordination difficulties
Techniques
■ Top-down approaches emphasize cognitive processes in motor plan-
ning (e.g., CO-OP, task-specific training, task analysis, motor learning
strategies, motor imagery)
■ Bottom-up approaches focus on improving underlying deficits in
strength, sensory processing, balance, etc. (e.g., NDT, SI)
■ Address timing, rhythm, reciprocal limb action, motor planning and
sequencing; can be promoted with new technologies and interactive
gaming (e.g., dance-dance revolution, Wii, virtual reality, interactive
metronome)
■ Encourage body awareness through movement and imitation of
postures
■ Use effective feedback schedules (constant/continuous vs.
intermittent), vary practice schedules
■ Diminish and then reintroduce distractions
■ Use contracting and rewards to increase attention to task
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Examples of Strategies for Motor

Planning/Coordination
Choose activities that are motivating to the child and that foster problem-
solving
Break down child-directed tasks into smaller steps; vary practice
Continued
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Examples of Strategies for Motor
Planning/Coordination—cont’d
Participation in community activities; encourage individual achievement

and peer modeling
Intervention Examples—Skin Integrity

General Principles
■ An area of primary prevention for children without means of inde-
pendent mobility/movement; creating opportunities for pressure relief
is key to prevention of pressure sores
■ Change positions frequently; monitor areas of potential pressure
■ Check pressure areas after orthotic/prosthetic use, prolonged position-
ing in equipment/seating systems; redness that persists 10–15 min,
check areas with poor sensation or circulation
■ Staging pressure ulcers (NPUAP): suspected deep tissue injury (purple/
discolored intact skin or blood-filled blister; stage I (nonblanchable
redness, skin intact, usually over a bony prominence); stage II (shallow
open ulcer, loss of dermis—partial thickness, red-pink wound bed);
stage III (full thickness, subcutaneous fat may be visible, may have
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tunneling/undermining); stage IV (full thickness with bone, tendon, or

muscle visible, may have tunneling/undermining); unstageable (full
thickness, wound bed covered by slough or eschar)
■ Types of burns: 1st degree (superficial; epidermis only), 2nd degree
(partial thickness; to the dermal layer), 3rd degree (full thickness; to
the fat layer), 4th degree (full thickness; involves tendon and muscle);
body surface area typically calculated using “rule of 9’s” or modified
Lund-Browder method
■ Signs of latex allergy: Contact dermatitis, hypersensitive immune sys-
tem response, hay fever or asthma-like symptoms; in severe cases,
anaphylactic response; children with spina bifida, complex genitouri-
nary disease, indwelling medical devices (e.g., nasogastric and GI
tubes) containing latex or with hx of multiple surgeries are particular-
ly susceptible; children with food allergies also at risk (foods contain-
ing proteins similar to latex)
Techniques—Rehab Management of Pediatric Burns

■ Early burn management: Pain control, hydration, débridement,
infection control with topical antimicrobials
■ Gentle, progressive ROM, mobility as permitted by medical
management
■ Time intervention during dressing changes, pain med administration
■ Scar management—short-term and long-term; skin care, pressure
garments, scar mobility
■ Child and family education key to limiting long-term complications
from severe burns
Examples of Dressings Used With Children

■ Semiocclusive: Penetrable to gas and water (e.g., traditional moist
dressings, foams, hydrocolloids, transparent films; antimicrobial and
bioactive products
■ Occlusive: Seals wound to prevent infection (e.g., temporary skin sub-
stitutes, cultured skin substitutes, skin grafting)
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Orthotic Devices—General Principles
■ Uses three-or four-point force system to prevent, assist, or control
motion at one or more joints
■ Devices are named for the joints that are encompassed:
■ CTLSO—cervicothoracolumbosacral orthosis
■ HKAFO—hip-knee-ankle-foot orthosis
■ EWHO—elbow-wrist-hand orthosis
■ Devices are typically custom-made, but “off the shelf” options are
available
■ All orthotic devices have the potential to cause skin breakdown if not
worn or fitted properly; periodic skin checks and education of child
and caregiver on proper donning and doffing are required
Axial Skeleton Orthotic Examples

Helmet/Skull Shaping
Unique attributes
• Custom-molded
• May need adjustments over time
Common uses
• Skull reshaping in plagiocephaly
Precautions
• Best results if started <1 yr old
• Device worn 23 hr/day
Continued
O&P
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O&P
Cervical Orthosis
Unique attributes
• Can be of flexible tubular PVC or Cervical Collar
plastic and foam
• May be customized
Common uses
• Used either to stabilize cervical
spine or to limit movement
• Head positioning and movement
support in torticollis
Precautions
• Not tolerated well by children
<4 mo
• Must be able to move away TOT Collar
from flexible collar for torticollis
application
Spinal Orthoses
Unique attributes
• Design depends on level of
control needed
• Can control motion/position in
all three planes
Common uses
• Scoliosis/posture
• Postsurgical
• Protection post-injury
Precautions
• Typically worn 23 hr/day
Milwaukee brace (CTLSO)
Continued
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Boston brace (TLSO)
Lower Limb Orthotic Examples

Hip Orthosis (HpO)—SWASH
Unique attributes
• Prevents hip adduction and
internal rotation
Common uses
• Reduces scissoring gait
• Reduces hip adduction in sitting
Precautions
• Must be worn outside of clothes
Standing-walking-and-sitting
hip orthoses (SWASH)
Hip Orthoses (HpO) for Hip Dysplasia

Unique attributes
• Maintains legs in flexed,
abducted position
• May be made out of straps
only or employ plastic and
leather components
Continued
O&P
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O&P
Common uses
• Conservative management
for hip disorders or dysplasia
• Prevents hip dislocation
Precautions
• Hygiene
Scottish-Rite brace (typically used

for Legg-Calvé-Perthes disease)
Hip-Knee-Ankle-Foot Orthosis (HKAFO)

Unique attributes
• Controls hip, knee, ankle
• Allows reciprocal or
swing-through gait
Common uses
• Standing and gait support
after spinal cord injury and
with myelodysplasias
Precautions
• Device weight may challenge
mobility
Parapodium/standing frame
HKAFOs
Continued
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Reciprocating Gait Orthosis (RGO)
Unique attributes
• Type of bilateral HKAFO—controls
hip, knee, ankle
• Prevents double hip flexion
(“jackknife”)
Common uses
• Reciprocal or swing-through gait
after spinal cord injury and with
myelodysplasias
Precautions
• Device weight may limit mobility
Knee Immobilizer
Unique attributes
• Holds knee in extension or limits
ROM
Common uses
• Postsurgical
• Night splinting
Precautions
• Adequate knee ROM needed
Knee-Ankle-Foot Orthosis (KAFO)

Unique attributes
• Various knee joints to allow manual
or independent locking/unlocking
• Ankle positioned in some
dorsiflexion can aid hip stability
Continued
O&P
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O&P
Common uses
• Stability during standing or gait
(knee, ankle, foot)
• Blocks knee flexion or recurvatum
• Can be used at night for splinting/
stretching
• Correction of deformity
Precautions
• Weight of device may limit mobility
Universal Foot Orthosis (UFO)

Unique attributes
• Adjustable dorsiflexion tension
Common uses
• Provides nighttime dorsiflexion stretch
• Prevents plantar flexion contractures
Precautions
• Must maintain strap tension
Rigid or Solid Ankle-Foot Orthosis (AFO)

Unique attributes
• Maintains stable ankle position,
resists movement
Common uses
• Supports ankle in standing
• Blocks ankle movement in gait
• Controls dorsiflexion/plantar flexion,
supination/pronation
• Aids clearance in swing
• Aids in control at knee/limits genu
recurvatum
• Positioning/protection
Continued
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Precautions
• Gait compensations because of
decreased ankle motion
• Excessive muscle tone
• Insufficient ankle ROM
• May limit functional activities (stair
climbing, sit to stand, creeping)
Articulated or Hinged Ankle-Foot-Orthosis (AFO)
Unique attributes
• Maintains stable ankle position,
allows movement
• Optional springs to assist
dorsiflexion or plantar flexion
• Optional block to resist plantar
flexion
Common uses
• Control/assist ankle in gait
• Aids clearance in swing
• Allows forward tibial movement
during midstance
Precautions
Posterior Leaf Spring (PLS)
Unique attributes
• Cut lines posterior to ankle create
springlike action, loaded via
weight-bearing
Common uses
• Assists ankle dorsiflexion ROM
• Aids clearance in gait
Precautions
• Does not provide medial-lateral
control
Continued
O&P
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O&P
Ground or Floor Reaction Orthosis

Unique attributes
• Orthosis donned from rear of
device
Common uses
• Prevents knee buckling/crouched
gait via ground reaction force
• Aids clearance in gait
Precautions
• May limit functional activities
(stair climbing, sit to stand,
rising from chair, running)
Supramalleolar Orthosis (SMO)

Unique attributes
• Controls pronation/supination;
hindfoot and midfoot motion
Common uses
• Reduces pronation during gait
and functional activities;
flexible pes planus
• Support to ankle/foot
movement during higher-
level balance skills
• Greater control than with FO
• Positioning (Wheaton brace)
Precautions
• Relatively good control of
ankle dorsiflexion/plantar
flexion needed
Continued
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Foot Orthosis (FO)
Unique attributes
• Typically lower profile, fits easily
in shoe or sneaker
• Controls pronation/supination
• Controls hindfoot and midfoot
Common uses
• Controls pronation/supination;
hindfoot and midfoot motion
Common uses
• Reduces pronation during gait
and functional activities; flexible
pes planus
• Support to ankle/foot movement
during higher-level balance skills
Precautions
• Good control of ankle
dorsiflexion/plantar flexion
needed
O&P
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O&P
Orthotic Garment Examples

Whole Body Devices
Unique attributes
• Flexible, customizable and
adjustable
• Provides sensory/proprioceptive
input
Common uses
• Provides support for functional
activities
• Influences muscle action/control
Precautions
• May be difficult to don and doff
• Child and family compliance
Upper Limb Orthotic Examples

Hand Orthosis (HO)
Unique attributes
• Controls hand/thumb motion/
position
Common uses
• Positioning/rest
• Holds thumb in opposition for
position or functional use
Precautions
• Hygiene
Continued
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Wrist Orthosis (WO)/Wrist-Hand Orthosis (WHO)
Unique attributes
• Controls wrist (and hand)
motion/position
• WHO also holds thumb in
opposition
Common uses
• Positioning/rest/protection
• Prevents contracture
• Holds wrist in extension for
position or functional use
Precautions
• Hygiene
Dorsal wrist splint
Volar wrist splint
Elbow Orthosis (EO)

Unique attributes
• Controls/resists elbow motion
• Can be custom-made or “off the
shelf”
Common uses
• Prolonged stretch
• Address contracture
Precautions
• Hygiene
Continued
O&P
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O&P
Elbow-Wrist-Hand Orthosis (EWHO)/Shoulder-Elbow-Wrist-Hand

Orthosis (SEWHO)
Unique attributes
• Controls shoulder (if SEWHO),
elbow, wrist, and hand motion
Common uses
• Postsurgical
Precautions
• Hygiene
Brace used postsurgically

in brachial plexus injury
Prosthetic Devices—General Principles

■ Uses pressure-tolerant areas for residual limb weight-bearing in socket
■ Devices are named for the level of amputation
■ Various components are used to achieve/compensate for a variety of
limb functions
■ Fabrication by use of negative and positive molds or via computer-
aided design
■ Types of prostheses—postoperative prosthesis, temporary prosthesis,
definitive prosthesis
■ May be used with surgical/elective or congenital amputations/limb
deficiencies
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Definitions of Congenital Limb Deficiencies
Categories of Deficiencies
■ “Longitudinal” deficiency—absence of structure(s) along the limb’s
longitudinal axis; normal skeletal components may exist below the
deficiency; can be total or partial deficiency; named for the body
part(s) involved; “nonstandard” prosthetic devices are often necessary
■ “Transverse” deficiency—limb deficiency where no distal structures
are present; can be total or partial deficiency; named for the body
part(s) involved
Terms Associated With Deficiencies
■ Amelia—absence of an entire limb
■ Aphalangia—absence of toe(s) or finger(s)
■ Adactylia—absence of toe(s) or finger(s) and associated metatarsals/
metacarpals
■ Apodia—absence of a foot or hand
■ Bifid bone—appearance of abnormal division in a bone
■ Hemimelia—absence of half a limb
■ Hypoplastic bone—incomplete or underdevelopment of bone
■ Phocomelia—absence of a limb segment, results in a “flipper limb”
■ Synostoses—two or more bones joined to form one bone
Limb Amputation Levels

Upper Body/Limb
• Interscapulothoracic
disarticulation (forequarter) [1]
• Shoulder disarticulation [2]
• Transhumeral [3] 1
• Elbow disarticulation [4] 2
• Transradial [5] 3
• Wrist disarticulation [6] 4
• Transcarpal 5
• Transmetacarpal [7] 6
• Transphalangeal 7
• Partial hand
Continued
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O&P
Limb Amputation Levels—cont’d

Lower Body/Limb
• Hemipelvectomy [1]
• Hip disarticulation [2]
• Transfemoral [3]
• Short: <35% of femur
• Medium: 35%–60% of femur
• Long: >60% of femur
• Supracondylar [4]
• Knee disarticulation [5]
• Transtibial [6]
• Very short: <20% of tibia 1
• Standard: 20%–50% of tibia 2
• Long: >50% of tibia present
• Ankle disarticulation or
Syme—heel pad is retained 3
for weight-bearing [7] 4
• Lisfranc—level of 5
tarsometatarsal joint with 6
disarticulation of all five 7
metatarsals [8] 8
• Chopart—level of talonavicular 9
and calcaneocuboid joints with
disarticulation through
midtarsal joint; calcaneus and
talus intact [8]
• Transmetatarsal [9]
• Transphalangeal—level of
metatarsophalangeal joint
with disarticulation of toe(s)
252
Page 253
Lower Limb Components—General Design

Exoskeletal Endoskeletal or Modular*
• Socket and foot encompassed in hard • Socket and pylon, covered by soft foam cover
O&P
outer cover • Also used for temporary and postoperative prostheses
• Offers greater durability
5:06 PM
Lower Limb Components—Transfemoral

3/11/10
Sockets Knees† Suspension

253
• Quadrilateral* • Single axis • Suction

• Ischial containment* • Polycentric axis* •Traditional
Types of friction •Roll-on silicone liner
• Mechanical* •Hypobaric
1815_Tab07_239-257.qxd
• Pneumatic •Soft belt

• Hydraulic (pediatric versions •Total elastic suspension (TES)*
available) •Silesian bandage*
•Pelvic band and hip joint
Braking/locking/control
• Stance control*
• Microprocessor control
• Dynamic swing phase control
• Variable cadence swing control
†
For most infants/very young children, either no knee or a locked knee is used for transfemoral devices.
Page 254
Lower Limb Components—Transtibial

O&P
Sockets Liners Suspension

5:06 PM
• PTB*—patellar tendon bearing • Pelite • Supracondylar cuff* • Thigh corset

• TSB—total surface bearing • Viscoelastic • Supracondylar system • Waist belt
• Supracondylar/suprapatellar • Sleeve
system • Pin/shuttle
*Most common components recommended for young children.
3/11/10
254
Lower Limb Components—Types of Feet
Conventional Dynamic-Response* (Energy Storing) Articulated Dynamic-Response
1815_Tab07_239-257.qxd
• Single axis • Nonarticulated long-keel • College Park True Step

• Multiple axis • Flex foot
• Solid ankle cushion • Springlite
heel (SACH) • Nonarticulated short-keel
• Stationary attachment • Seattle foot
flexible endoskeletal • Carbon Copy II
(SAFE)
• Stored-energy (STEN)
*Most common components recommended for young children.
Page 255
Examples of Common Prosthetic Prescriptions for Children

Transhumeral Transradial Transfemoral Transtibial
O&P
5:06 PM
3/11/10
255
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Upper Limb Components—Types of Hands or “Terminal Devices”

Active (Older, Active Children) Passive (Typical for Infants, Young Children)
• Hook • Cosmetic
• Voluntary opening (VO) design (closed at rest) • Functional
• Voluntary closing (VC) design (open at rest)
• Prosthetic hand
• Cable-powered
• External powered/myoelectric
Page 256
O&P
5:06 PM
Upper Limb Components—Transhumeral and Transradial

Sockets Joints Cable Control Suspension
• Rigid frame with • Elbow • Single-control cable • Harness-based
3/11/10
flexible inner liner • Flexible hinge (Bowden) • Figure 8

• Rigid inner socket • Rigid hinge • Dual-control cable • Soulder saddle and
256
• Growth liner for • Internal locking • Body movement chest strap
adjusting to • Wrist controls • Self-suspending socket
changes in • Quick disconnect • Glenohumeral • Muenster
residual limb unit forward flexion Northwestern
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• Locking unit • Biscapular • Supracondylar

• Flexion unit abduction • Suction socket
• Glenohumeral • Socket with air valve
depression/elevation • Gel sleeve with
• Nudge control locking pin
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Basic Lower Limb Prosthetic Checkout—Items
for Examination
In standing • Check for complaints of pain/discomfort
• Anteroposterior alignment
• Foot flat on floor
• Maintenance of knee stability
• Medial lateral alignment
• Foot flat on floor
• Check pressure on brim of socket
• Length of prosthetic device
• Level pelvis
• Check foot position
• Check socket fit
• Check prosthesis length
• Suspension—correct fit/support
• Check ability to get on/off floor, kneel
down and return to stand, etc.
In sitting • Check comfort with hips/knees at 90º
• Equal weight-bearing
• Socket should remain secure
• Check soft tissues in popliteal space
• Check ability to don/doff correctly (child
and caregivers)
During walking • Observe for gait deviations—frontal,
sagittal, and transverse planes
• Check for piston action
• Should not exceed 1⁄4 inch
• Adjust suspension if necessary
• Check function (knee stability and foot
clearance) on level and nonlevel surfaces
(including stairs, curbs, ramps)
• Check for any sounds that could indicate
poor function of components or poor
suspension
Residual limb after removal • Check for evidence of weight-bearing on
of prosthesis weight-tolerant areas of limb
• Check for evidence of skin irritation or
breakdown
O&P
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AT
Definitions—Assistive Technology (AT)

• Assistive technology* “Technology designed to be utilized in an
assistive technology device or assistive
technology service”
• Assistive technology “Any item, piece of equipment, or product
device* system, whether acquired commercially,
modified, or customized, that is used to
increase, maintain, or improve functional
capabilities of individuals with disabilities”
• Assistive technology “Any service that directly assists an indi-
service* vidual with a disability in the selection,
• Types of services can acquisition, or use of an assistive device”
include: • Evaluation of needs/functional impact
of AT
• Purchasing, leasing, acquiring a device
• Selecting, designing, adapting, fitting,
repairing, replacing a device
• Training and technical assistance
• Individual with a disability* “Any individual of any age, race, or eth-
• Functional categories nicity who (i) has a disability; and (ii) who
is or would be enabled by an assistive
technology device or an assistive technol-
ogy service to minimize deterioration in
functioning, to maintain a level of func-
tioning, or to achieve a greater level of
functioning in any major life activity”
• Personal care and management for
work, education, recreation, home/
family, community
• Sitting and mobility for work, education,
recreation, home/family, community
• Transportation for work, education,
• Communication for work, education,
*Definitions from the Assistive Technology Act of 1998.
http://www.nifl.gov/linc/collections/policy/ata.txt
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259
Definitions—Assistive Technology (AT)
• “No-tech” device Typically refers to a device that is not pow-
ered electronically, is simple in design and
use, and may require little to no training
• “Low-tech” device Typically refers to a device that requires
computer hardware or software for use,
usually of higher cost, and requires training
• “High-tech” device Typically refers to a device that requires
computer hardware or software for use,
usually of higher cost, and requires training
• Universal design “A concept or philosophy for designing
and delivering products and services that
are usable by people with the widest possi-
ble range of functional capabilities, which
include products and services that are
directly accessible (without requiring
assistive technologies) and products and
services that are interoperable with assis-
tive technologies”
AT Evaluation Schemes: SETT framework—

Student, Environment, Task, Tools
Available online: http://sweb.uky.edu/~jszaba0/SETT2.html
• Student What does the student need to do? What are
the student’s special needs and current abilities?
• Environment What are the instructional and physical
arrangements? Are there special concerns?
What materials and equipment are currently
available in the environments?
What supports are available to the student and
the people working with the student on a daily
basis? How are the attitudes and expectations
of the people in the environment likely to
affect the student’s performance?
Continued
AT
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AT
• Task What activities occur in the student’s natural

environments that enable progress toward
mastery of identified goals? What is everyone
else doing? What are the critical elements of
the activities? How might the activities be
modified to accommodate the student’s special
needs?
• Tools What no-tech, low-tech, and high-tech options
should be considered for inclusion in an AT
system for a student with these needs and
abilities doing these tasks in these environ-
ments? What strategies might be used to invite
increased student performance? How might a
student try out the proposed system of tools in
the customary environments in which they
would be used?
AT Evaluation Schemes: FEAT—Functional

Evaluation for Assistive Technology*
Includes Five Scales
• Contextual matching Information on setting specific demands; can
inventory be completed by teacher, employer, family
member, or student/employee via interview
by AT professional
• Checklist of strengths Information on person-specific characteristics;
and limitations can be completed by teacher, employer,
family member, or student/employee via
interview by AT professional
• Checklist of technology Additional information on person-specific
experiences characteristics including past/current use of
technology; can be completed by student/
employee via interview by AT professional
• Technology characteristics Information on device-specific characteris-
inventory tics; completed by AT professional
Continued
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261
• Individual technology To evaluate the compensatory effectiveness
evaluation scale of the proposed at adaptation; completed by
AT professional
Summary and Provides summary of assessment informa-
recommendations tion, recommendations, and scheduled
booklet follow-up to assess implementation;
completed by AT professional
*Raskind & Bryant (2002); available for purchase through National Professional Resources, Inc.
http://www.nprinc.com/assist_tech/feat.htm
AT Evaluation Schemes: QIAT—Quality

Indicators for Assistive Technology*
Quality Indicators for Assessment of AT
■ Procedures for all aspects of AT assessment are clearly defined and
consistently applied
■ AT assessments are conducted by a team with the collective knowl-
edge and skills needed to determine possible AT solutions that
address the needs and abilities of the student, demands of the
customary environments, educational goals, and related activities
■ All AT assessments include a functional assessment in the student’s
customary environments, such as the classroom, lunchroom, play-
ground, home, community setting, or workplace
■ AT assessments, including needed trials, are completed within
reasonable time lines
■ Recommendations from AT assessments are based on data about the
student, environments, and tasks
■ The assessment provides the IEP team with clearly documented rec-
ommendations that guide decisions about the selection, acquisition,
and use of AT devices and services
■ AT needs are reassessed any time changes in the student, the envi-
ronments, or the tasks result in the student’s needs not being met
with current devices or services
*The QIAT Consortium (Revised, 2005). Quality Indicators for Assistive Technology Services.
AT
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AT
Quality Indicators for Evaluation

of the Effectiveness of AT
■ Team members share clearly defined responsibilities to ensure that
data are collected, evaluated, and interpreted by capable and credible
team members
■ Data are collected on specific student achievement that has been
identified by the team and is related to one or more goals
■ Evaluation of effectiveness includes the quantitative and qualitative
measurement of changes in the student’s performance and achievement
■ Effectiveness is evaluated across environments during naturally
occurring and structured activities
■ Data are collected to provide teams with a means for analyzing student
achievement and identifying supports and barriers that influence AT
use to determine what changes, if any, are needed
■ Changes are made in the student’s AT services and educational program
when evaluation data indicate that such changes are needed to improve
student achievement
■ Evaluation of effectiveness is a dynamic, responsive, ongoing process
that is reviewed periodically
Quality Indicators
Quality Indicators also available for the following (see http://www.qiat.org):
■ Quality Indicators for Consideration of AT Needs
■ Quality Indicators for Including AT in the IEP
■ Quality Indicators for AT Implementation
■ Quality Indicators for AT Transition
■ Quality Indicators for Administrative Support of AT Services
■ Quality Indicators for Professional Development and Training in AT
262
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263
AT Considerations for the IEP Team*
Domains/tasks to be considered; for each describe:
• Strategies, accommodations, tool currently used
• Any continuing barriers encountered related to tasks
• New/additional AT to be tried or investigated further
• Need for consult with AT specialist
Physical Communication
• Vision and hearing • Speech production and use
• Health • Receptive and expressive language
• Motor activities/mobility • Voice
• Speech mechanism • Fluency
• Positioning/seating • Augmentative and alternative
• Mechanics of writing communication
• Computer access
Cognitive Social Competence
• Aptitude • Adaptive behaviors
• Mental processing • Social skills
• Knowledge application • Environmental needs
• Problem-solving • Assumes responsibility
• Learning and studying
Academic Performance Vocational Function
• Basic reading/comp • Work behaviors
• Mathematic calculation • Following directions
• Reasoning and application • Need for job supports
• Written and oral expression • Job interests/preferences
• Learning style • Job-specific abilities
• Impact of disability • Interpersonal relationships
• Socialization
Recreation/Leisure Function Environmental Function
• Use of free time • Relationship with family
• Maintenance of fitness • Relationship with peers
• Community recreation use • Dominant language
• Social involvement • Cultural influences
• Family expectations
• ADLs and environmental controls
• Services received
• Economic influences
Source: Adapted from Denham, A.P., and Zabala, J.S.: Assistive Technology Consideration Guide
for IEP Teams. 1999.
AT
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AT
AT Training Considerations
Training should be provided and aimed at the unique needs of the
learner. The following individuals should be considered for training:
• The child/user of AT device/solution
• The child’s family and other caregivers
• The child’s regular and, if appropriate, special education teachers
• Paraprofessionals, classroom aides, and other school support personnel
who interact with the child as he/she uses the AT
• Related service personnel who interact with the child as he/she uses
the AT
Questions to Consider:
• What is the purpose of • Is device/solution ready to use? What
device/solution? must be done to prepare device/
• What are the benefits and solution?
drawbacks of device/solution? • What does the child, family, other
• Is it relatively easy and school personnel, and caregivers
comfortable to use device/ need to know to use device/solution
solution? safely and effectively?
• How does the child feel • Is training (in person or via manual)
about using device/solution? provided by provider/manufacturer
• In what situations and of device/solution? Are there addi-
environments can device/ tional training costs?
solution be used? • How much time is needed for the
• Is device/solution powered training?
in some way such that • Who is responsible for performing
access to electricity or and paying for repairs, maintenance,
battery life needs to be and upgrades?
considered? • Are loaner options available?
• How long can one expect
device/solution to last
(“life expectancy”)
• What is the history of
reliability and durability of
device/solution?
Source: Adapted from Illinois Assistive Technology Program Funding Manual.
http://www.iltech.org/fm-considerations_choosing.asp
264
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265
Checklist—Letters of Medical Necessity for AT
Items to Confirm Before Writing
■ Verify child’s insurance coverage
■ Verify insurance coverage includes child’s diagnosis
■ Verify insurance coverage includes requested device(s)
■ Verify that equipment vendor, if one is being used, is a provider for
the intended insurance coverage
■ Verify any relevant information from the summary plan description
that might inform your letter writing
Demographic Information
■ Date of letter/report
■ Child’s name and date of birth
■ Name of insured, group/policy #
■ Names of therapist and physician of record
■ Date of child’s last examination/evaluation
■ Relevant diagnostic codes
Pertinent History and Examination/Evaluation

■ Relevant developmental, medical, and surgical history
■ Relevant medical diagnoses with explanation
■ Relevant developmental, medical, and functional evaluative
information
■ Relevant information on prognosis
■ Relevant results of previous interventions
■ Link child’s specific limitations to the improvements that would be
gained
Body of the Letter

■ Specific details about equipment that is needed
■ Any additional or supplemental options or parts that are needed
■ Rationale for each device/component
AT
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AT
■ Results of any trials that have been successfully done with same or
similar equipment
■ Explain why alternative or less costly equipment would not meet
child’s needs
Documenting Medical Necessity

■ How device would improve function, increase independence, prevent
disability, correct/reduce abnormality, decrease future costs, increase
participation in age-related social roles
■ If replacing existing equipment, rationale for replacement
■ Information related to growth and change over time
■ Relate rationale to definition of medical necessity for insurance carrier;
for Medicaid, check your state’s requirements
■ Key details about device selected, how it was selected, rationale for
its use, relate device features to child’s needs
Summary
■ Reiterate important details from letter/report
■ Emphasize the logical conclusion of how the child would benefit from
device including any cost savings or replacement of other
devices/services
■ Summarize the insurance carrier’s coverage of device
■ Signature, qualifications, and contact information of individual writing
the letter
■ If appropriate, include pictures of device, including before and after
pictures of child (with permission)
■ Include copies of relevant referrals/prescriptions
■ Provide copies of letter to child’s family and relevant heath-care
professionals
Considerations for an Appeal After Denial

■ Always keep copies of all letters and supporting documentation
■ If not done already, get a copy and consult the benefit booklet and
relevant policy definitions
■ Keep in mind the time limits that may be enforced on an appeal
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267
■ If not supplied, obtain a detailed rationale for the denial; this may
have to be requested by the insured
■ Focus appeal on specific reasons for denial—typically, dispute of
medical necessity, an express policy exclusion or change, an implied
policy exclusion
■ Provide specific evidence to refute each point in denial
Other Important Concepts

■ Insurance coverage is a contract between the carrier and the insured
■ Insurance carriers must disclose what is covered and what is not
covered under the policy
■ Consider your “audience”; avoid jargon, acronyms, abbreviations
■ Make the child a real person to the reader, someone who is facing
real challenges
■ Do not hesitate to contact the insurance company with questions at
any point in the process; document all such communication
■ If you do not intend to appeal a denial on behalf of the child, notify
the insured so that they may take action if desired
Funding Options
■ Medical—private insurance, Medicare, Medicaid, state-run Children’s
Insurance Programs (CHIPs)
■ Educational—Part B (school age) and Part C (early intervention) of
IDEA
■ Vocational/foundational—state vocational rehabilitation agencies,
Centers for Independent Living (for adolescents in transition and
adults), auto manufacturer’s adaptive equipment reimbursement pro-
grams, National Assistive Technology Advocacy Project, associations
(e.g., MDA, UCPA, Lions Clubs, AMBUCS)
■ Governmental—state or regional AT projects/loan programs
(e.g., AT loan programs, Access to Telework Loan Programs),
State Telecommunications Equipment Distribution Programs
AT
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AT
Assistive Technology Examples*

Personal Care Management
Bathroom aids—bathing, Activities of daily living
toileting —dressing, feeding
Continued
268
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269
Environmental controls Evacuation aids
Photo Courtesy of Garaventa Lift

Company (Evacu Trac)
Photo Courtesy of Safety Chairs,

Santa Rosa, CA
*Examples are for illustration purposes and are not inclusive of all types of available products
and devices.
AT
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AT
Seating and Mobility

Seating and positioning
Wheelchairs/mobility
Continued
270
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271
Seating and Mobility

Ambulatory aids
Continued
AT
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AT
Recreational mobility
Photo Courtesy of Flaghouse, Photo Courtesy of Enabling

Inc. ©2009. Technologies, LLC. ©2005.
272
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273
Transportation and Environmental Access
Car and bus safety
Photo Courtesy of Qstraint. Photo Courtesy of Qstraint.
Continued
AT
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AT
Ramps and lifts Car adaptation
Photo Courtesy of Sammons

Preston.
Photo Courtesy of Flaghouse, Photos Courtesy of AEVIT.

Inc. ©2009.
274
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275
Communication—Augmentative and Alternative Devices
No- and low-tech
Photo Courtesy of Enabling Devices.
Photo Courtesy of Enabling Devices. Photo Courtesy of Enabling Devices.

High-tech
Photo Courtesy of Tobii ATI. Photo Courtesy of Tobii ATI.
AT
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AT
Computer Access
Alternative input software/hardware
Alternative output software/hardware and writing aids
• Alternative/adapted keyboards • Text to speech
• Onscreen keyboard • Screen readers
• Key guards • Word prediction/completion
• Alternative pointing devices/ • Magnifiers
mouse/trackball • Braille display
• Touch screen • Braille embosser/printer
• Speech to text/dictation/voice • Oversized monitor
recognition • System accessibility software
276
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277
School and Play
Classroom supports
Adapted equipment—playground and physical education
Photo Courtesy of Flaghouse, Photo Courtesy of Flaghouse,

Inc. ©2009. Inc. ©2009.
Continued
AT
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AT
Photo Courtesy of Flaghouse,

Inc. ©2009.
Select References by Tab

Advocacy
■ Americans with Disabilities Act. 1990. Retrieved June 15, 2008, from
http://www.ada.gov/pubs/ada.htm.
■ Assistive Technology Act of 1998; Amended 2004. 2004. Retrieved
June 15, 2008, from http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?
dbname=108_cong_public_laws&docid=f:publ364.108.
■ Child Abuse Prevention and Treatment Act as Amended by the Keeping
Children and Families Safe Act of 2003. 2003. Retrieved June 15, 2008,
from http://www.acf.hhs.gov/programs/cb/laws_policies/cblaws/capta03/
index.htm.
■ Health Insurance Portability and Accountability Act of 1996. 1996. Retrieved
June 15, 2008, from http://aspe.hhs.gov/admnsimp/ pl104191.htm.
■ Individuals with Disabilities Education Improvement Act of 2004. 2004.
Retrieved June 15, 2008, from http://frwebgate.access.gpo.gov/
cgi-bin/getdoc.cgi?dbname=108_cong_public_laws&docid=f:publ446.108.
■ Rehabilitation Act of 1973. 1973. Retrieved June 15,2008, from
http://www.dotcr.ost.dot.gov/Documents/ycr/REHABACT.HTM.
■ Social Security Online. Benefits for Children with Disabilities. 2008.
Retrieved August 4, 2008, from http://www.ssa.gov/pubs/10026.html.
278
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279
Examination/Evaluation
■ American Physical Therapy Association: Guide to physical therapist
practice. 2nd ed. Physical Ther. 2001; 81:9–746.
■ Ammani Prasad, S., Randall, S.C., and Balfour-Lynn, L.M.: Fifteen-count
breathlessness score: An objective measure for children. Pediatr
Pulmonol. 2000; 30:56–62.
■ Atwater, S.W., Crowe, T.K., Deitz, J.C., and Richardson, P.K.: Interrater
and test-retest reliability of two pediatric balance tests. Physical Ther.
1990; 70:79–87.
■ Balfour-Lynn, I.M., Prasad, S.A., Lavery, A., et al: A step in the right
direction: Assessing exercise tolerance in cystic fibrosis. Pediatr
Pulmonol. 1998; 25:278–284.
■ Bartlett, B., and Birmingham, T.: Validity and reliability of a pediatric
reach test. Pediatr Physical Ther. 2003; 15:84–92.
■ Bedros, A.A., and Mann, J.P.: Lymphadenopathy in children. Adv Pediatr.
1981; 28:341–376.
■ Bohannon, R.W., and Smith, M.B.: Interrater reliability of a modified
Ashworth scale of muscle spasticity. Phys Ther. 1987; 67:207–208.
■ Borg, G.A.V.: Psychophysical bases of perceived exertion. Med Sci
Sports Exerc. 1982; 14:377–381.
■ Butler, P., Engelbrecht, M., et al.: Physiological cost index of walking
for normal children and its use as an indicator of physical handicap.
Dev Med Child Neurol. 1984; 26:607–612.
■ Cusick, B.D., and Stuberg, W.A.: Assessment of lower-extremity align-
ment in the transverse plane: Implications for management of children
with neuromotor dysfunction. Phys Ther. 1992; 73:3–5.
■ Daley, A.J., Copeland, R.J., Wright, N.P., and Wales, J.K.H.: Protocol
for: Sheffield obesity trial (SHOT): A randomised clinical controlled
trial of exercise therapy and mental health outcomes in obese adoles-
cents. BMC Public Health. 5:113, 2005. Accessed June 15, 2009, from
http://www.biomedcentral.com/1471-2458/5/113.
■ Donohoe, B., Turner, D., and Worrell, T.: The use of functional reach as
a measurement of balance in boys and girls ages 5 to 15 years.
Pediatr Physical Ther. 1994; 6:189–193.
■ Effgen, S.K.: Meeting the Physical Therapy Needs of Children.
Philadelphia: F.A. Davis, 2005.
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■ Ewing-Cobbs, L., Levin, H.S., Fletcher, J.M., Miner, M.E., and

Eisenberg, H.M.: The children’s orientation and amnesia test:
Relationship to severity of acute head injury and to recovery of
memory. Neurosurgery. 1990; 27:683–691.
■ Florence, J.M., Pandya, S., King, W.M., Robison, J.D., Baty, J.,
Schlerbecker, J., and Signore, L.C.: Intrarater reliability of manual
muscle test (Medical Research Council Scale) grades in Duchenne’s
muscular dystrophy. Phys Ther. 1992; 72:115–126.
■ Franjoine, M.R., Gunther, J.S., and Taylor, M.J.: Pediatric balance
scale: A modified version of the Berg balance scale for the school-
aged child with mild to moderate motor impairment. Pediatr Physical
Ther. 2003; 15:114–128.
■ Glascoe, F.P.: Commonly Used Screening Tools. 2007. Accessed
February 2, 2008, from http://www.dbpeds.org/articles/detail.cfm?
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Lippincott Williams & Wilkins, 2002.
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AT
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INDEX
■ Rifton Equipment. Eleven Point Checklist for Writing an Effective Letter of

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Index
Note: Page numbers followed by “f” and “t” indicate figures and tables, respectively.
Abuse/neglect, signs of, 5 Behavior supports, positive, 204–206

Achondroplasia, 130f, 130t Blood pressure, 153t
Acquired brain injury (ABI), 118t, 119f Blout disease, 102t–103t, 103f
Aerobic capacity/endurance/exertion, 24, Body mass index, 61, 67f, 69f
25t, 26t, 27f Body weight support treadmill training
Airway clearance, 219 (BWSTT), 214t
Amputation levels, 251f, 252f Breath sounds, 22, 22t, 23f
Angelman syndrome, 131t Burns, 129t, 238
Anthropometrics, 60–69, 62f–69f Cancers, childhood, 132t–133t
Apgar score, 147 Cardiovascular-pulmonary system, 9,
Aquatic therapy, 209t 17–27, 19–20, 20t, 21f, 99, 126–128,
Arterial blood gases (ABG), 165t, 166t 127t–128t, 147t
Arthrogryposis multiplex congenita Cerebral palsy, 120t–121t
(AMC), 101t, 102f Charcot-Marie-Tooth (CMT) disease,
Assessment tools, 85t–98t 131t–132t, 132f
Assistive technology (AT), 258t–259t, Children’s Effort Rating Table, 26f
259t–260t, 260t–261t, 261, 263t, 264, Children’s Orientation and Amnesia Test
265–266, 268f–278f (COAT), 12t–14t
Asthma, 126t, 127f Cognitive Orientation to Daily
Autistic spectrum disorders (ADS), Occupational Performance, 210t
119t–120t Coma scale, pediatric, 28t–29t
Balance/posture, 50, 51t–52t, 53t, 220, Complete blood count (CBC), 162t–164t
221f Conductive education (CE), 210t
288
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289
Constraint-induced movement therapy Limbs, congenital deficiencies, 251
(CIMT), 212t Locomotion, 226, 227f–228f, 229t
Cranial/peripheral nerve integrity, 29t Locomotor training (LT), 214t
Cri du chat syndrome, 133t, 134f Lower limb, 72f, 72t, 74t, 75f–77f, 79,
Cystic fibrosis (CF), 134t, 135f 241f–247f
Dermatomes, 40f Lower limb deficiency, 110f, 110t
Developmental coordination disorder Lymphatic/immune system, 11–12, 11f
(DCD), 121t, 122f Marfan syndrome, 139t
Developmental dysplasia of the hip Mechanical modalities, indications/
(DDH), 104t, 105f contraindications/precautions, 201t–202t
Down syndrome, 135t, 136f Medications, 184t–197t
Dyspnea scales, 25t Motor control deficits//weakness, 43t,
Ehlers-Danlos syndrome (EDS), 136t 232f
Electrical stimulation, 222–223 Motor development/motor milestones,
Electrocardiography (ECG), 170–172, 173f, 46t–49t, 232–233, 233f–234f
173t–174t, 174f–175f Motor learning, 50, 215t
Endocrine system, 10 Motor planning/coordination, 235,
Exercise, 203t, 232t 236f–237f
Fetal alcohol syndrome, 137f, 137t Motor testing, types of, 42
Fever, warning signs in, 153–154 Muscle strength/force production,
Flexibility, 75f–77f, 223, 224f–225f 77t–78t, 78–79
Gait, 54–55, 56t, 57f, 58–59 Muscle tone/spasticity measurements,
Gastrointestinal system, 10, 147t 44t–45t
Genitourinary system, 11, 147t Muscular dystrophies, 140t–142t, 142f
Gestational age, 150t–151t Musculoskeletal system, 10, 60–79, 99,
Growth plate/physeal fractures, 101–117
105t–106t, 106f Myotomal distribution, 42f
Hemophilia, 138t Neonatal abstinence syndrome, 148t
Hippotherapy, 213t Neonatal intensive care unit (NCU), 147,
Imaging studies, 176t–181t 148t–149t, 149f
Immunizations, 182t–183t Neurodevelopmental treatment approach
Inborn errors of metabolism (IEM), (NDT), 216t
138t–139t Neurofibromatosis, 143t
Integumentary system, 10, 79–84, 99, 129, Neuromotor development and sensory
147t, 237–238 integration, 30t–31t, 32f–35t
Joint integrity/mobility, 73t–74t, 75f–77f Neuromuscular system, 9, 28–60, 99,
Juvenile idiopathic arthritis (JIA), 118–125, 147t
106t–107t, 107f Newborns, 147t, 148t
Laboratory tests, 155t–162t Nursemaid’s elbow, 111f, 111t
Lateral discoid meniscus, 108f, 108t Obstetrical brachial plexus paralysis
Legg-Calvé-Perthes disease, 109f, 109t (OBPP), 122t–123t, 123f
INDEX
Orthotic devices, 239, 239f–241f, Scoliosis, 70f, 71, 71f, 114t–115t,
241f–247f, 248f–250f s115f
Osteogenesis imperfecta (OI), Sensory defects, terminology,
144t 41t
Overuse injuries, 113t, 114f Sensory integrative treatment
Pain assessment, 154f, 154t (SIT), 217t–218t
Palpation, of liver/lymph nodes/ Sensory integrity, 40f
spleen, 11f Sensory testing, types of, 41
Patient-client management Service delivery, key principles
model, 7f in, 198–200
Pervasive developmental Sickle cell disease, 144t–145t
disorder (PDD), 119t–120t Skin integrity/lesions, 79–80, 80t,
Plagiocephaly, 112f, 112t 81f–84f, 237–238
Posture/alignment, 35t–36t, 70f, Slipped capital femoral
71, 71f, 72f, 72t–73t epiphysis (SCFE), 116f, 116t
Prader-Willi syndrome, 140t Spina bifida, 124t
Pressure ulcers, 80, 80f Spinal cord injury, 125t
Prosthetic devices, 250, 253t, Spinal muscular atrophy, 145
255f, 255t, 256t, 257t Spirometric values, 167t
Pulmonary function tests (PFTs), Sputum, 23–24
166, 167t, 168t, 169t Temperature, body, 153t
Pulses, 18, 18f, 19f, 152t Thermal modalities, 201t
Radiology/imaging, 176t–181t Torticollis, 117f, 117t
Range of motion, 73, 74t Transhumeral/transradial
Rare disorders, information components, 256t
sources, 100 Upper limb, 73, 73t, 74t, 78,
Reflex integrity, 36, 37f–39f 248f–250f, 251f
Reflex testing, 32f–35f Vital signs, 152t, 153–154
Respiratory rate, 152t Wound dressings, 238

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Robin L. Dole, PT, DPT, EdD, PCS

A Davis’s Notes Book

Copyright © 2010 by F. A. Davis Company

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Acquisitions Editor: Margaret M. Biblis

Waterproof and Reusable

Write directly onto any page of Peds Rehab Notes

ADVOCACY EXAM/EVAL DX LABS MEDS INTERVEN O&P AT

Look for our other Davis’s Notes titles

Neuro Notes: Clinical Pocket Guide Ortho Notes 2: Clinical

Individuals with Disabilities Act (IDEA)

■ Least restrictive environment

Rehabilitation Act of 1973—Section 504

Assistive Technology Act

Health Insurance Portability

■ Notices of privacy practices

Health Plans and Providers

Child Abuse Prevention and Treatment and

Governmental Benefits for Disabled Children

Selected Internet Resources for Advocacy

■ Physical Activity Guidelines for Americans: Active Children and

categories • Plan of care – including interventions, and

• Clinical judgements communication, and

History Taking—Relevant Items

Current Medical History

Systems Review/Basic Screening

Palpation of Lymph Nodes, Spleen, and Liver

Notes: Check size, location, pain, consistency; palpable nodes in children

Children’s Orientation and Amnesia Test (COAT)

Children’s Orientation and Amnesia Test (COAT)

Children’s Orientation and Amnesia

■ Learning style and learning preferences of child and family (educational

HOTV can be accessed for free at: http://www.preventblindness.org/eye_tests/

Contextual factors—environmental qualities (including personal and envi-

■ Capillary refill—measure the time in seconds it takes for normal color-

Palpation of Peripheral Pulses

■ Systolic murmurs: Sounds that occur between S1 and S2 can

Scale for Grading Cardiac Murmurs*

Pulmonary—Ventilation and Respiration/Gas Exchange

■ Normal air-filled lung should sound low-pitched and drumlike

Breath Sound Description

0.5 Very, very light

10 Very, very heavy

■ Dalhousie Dyspnea Scales—three pictorial scales that measure the

and word descriptors

Pediatric Coma Scale

Cranial and Peripheral Nerve Integrity

Neuromotor Development and Sensory Integration

Primitive Reflexes—Appearance and Timing

Attitudinal Reflexes—Appearance and Timing

Protective Extension Reactions—Appearance

Postural Fixation/Tilting Reactions—Appearance

Testing of Selected Reflexes

• R—turns head and

Palmar grasp— • S—pressure placed

Plantar grasp— • S—pressure placed

Implications: Persistence of primitive reflexes (such as those listed on

Testing of Selected Reflexes—cont’d

Symmetric tonic neck • S—flexion or

• R—arms flex with

Testing of Selected Postural Responses