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Pediatric Pediatric Musculoskeletal (MSK) Musculoskeletal (MSK) ExaminationExaminationExaminationExamination

Janalee Taylor, RN, MSN, CPNPJanalee Taylor, RN, MSN, CPNPClinical DirectorClinical Director

Division of RheumatologyDivision of Rheumatology

DisclosureDisclosure

Member of the Executive Committee and Member of the Executive Committee and Board of Directors of the National Arthritis Board of Directors of the National Arthritis

Foundation and Speaker’s BureauFoundation and Speaker’s Bureau

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Evidence Based Medicine InformationEvidence Based Medicine Informationo Beighton PH & Horan FT. Dominant inheritance in familial generalized articular Hypermobility. Journal of

Bone and Joint Surgery British 1970; 52 (1): 145-147.o Bickley LS., Szilagyi PG., Bates’ Guide to Physical Examination and History Taking, 8th Edition, Lippincott

Williams & Wilkins, 2003; 489-535, 623-726.o Billiau AD., et al., Temporomandibular joint arthritis in juvenile idiopathic arthritis: prevalence, clinical and

radiological signs, and relation to dentofacial morphology J Rheumatol. 2007 Sep;34(9):1925-33o Cassidy J., et al., Textbook of Pediatric Rheumatology, 5th Edition, Elsevier, Inc., 2005.o Doherty M., et al., Rheumatology Examination And Injection Techniques, o Katz PP, et al. Patient Outcomes in Rheumatology; A Review of Measures. Arthritis Care & Research

2003; 49 (5) Supplemento Lovell DJ, et al. Development of Validated Disease Activity and Damage Indices for Juvenile Idiopathic

Inflammatory Myopathies. Arthritis Rheum 1999; 42: 2213-2219.o Polley HF., & Hunder GG., Rheumatologic Interviewing and Physical Examination of the Joints, 2nd Edition,

W.B. Saunders Company, 1978.o Ryan-Wenger NA Core Curriculum for Primary Care Pediatric Nurse Practitioners Mosby Elsevier Inco Ryan-Wenger NA., Core Curriculum for Primary Care Pediatric Nurse Practitioners, Mosby, Elsevier Inc.,

2007, 611-637, 841-859.o Weiner DS., Pediatric Orthopedics for Primary Care Physicians, 2nd edition, Cambridge University Press,

2004.o West S., Rheumatology Secrets, 2nd edition, Philadelphia, Hanley & Belfus Inc. 2002; 451-452, 488.o Wolfe F, et al. Arthritis and Rheumatism; 1990 33 (2): 160-172 o Yunus MB, Masi AT. Juvenile Primary Fibromyalgia Syndrome A Clinical Study of Thirty-Three Patients

and Matched Normal Controls. Arthritis and Rheumatism; 28 (2): 138-145.

What’s Different in Children What’s Different in Children and Adolescents?and Adolescents?and Adolescents?and Adolescents?

•Children are anatomically and physiologically different from adults

•Techniques for assessment, physical findings, & abnormalities in q , p y g ,young patients differ as well

•Tremendous variations in physical, cognitive, & social development compared to adults

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Conditions Occurring inConditions Occurring inInfancy / Early ChildhoodInfancy / Early Childhood

Genu varum (“bowlegs”)Genu varum (“bowlegs”)Genu valgum (“knockGenu valgum (“knock--knees”)knees”)Metatarsus adductusMetatarsus adductusInternal tibial torsionInternal tibial torsionInternal tibial torsionInternal tibial torsionFemoral anteversionFemoral anteversion

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Conditions Occurring inConditions Occurring inToddler through School AgeToddler through School Age

ToeToe--walkingwalkingMetatarsus adductusMetatarsus adductusPes planusPes planusTransient toxic synovitisTransient toxic synovitisTransient toxic synovitisTransient toxic synovitisLeggLegg--Calve PerthesCalve PerthesGrowing painsGrowing pains

Features Not Associated with Features Not Associated with Growing PainsGrowing Pains

LimpLimpJoint erythemaJoint erythemaNight sweatsNight sweatsWeight lossWeight lossFever Fever AdenopathyAdenopathyBone pain disproportionate to physical findingsBone pain disproportionate to physical findingsBone pain disproportionate to physical findingsBone pain disproportionate to physical findings

Neoplasms can present as musculoskeletal complaints (ie; Neoplasms can present as musculoskeletal complaints (ie; ALL, neuroblastoma, Ewings Sarcoma, lymphoma) ALL, neuroblastoma, Ewings Sarcoma, lymphoma)

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Conditions Occurring in Conditions Occurring in Adolescence and PubertyAdolescence and Puberty

P t ll f l i dP t ll f l i dPatellofemoral pain syndromePatellofemoral pain syndromeOsgoodOsgood--Schlatter diseaseSchlatter diseaseSindingSinding--LarsenLarsen--Johansson disease Johansson disease Sever’s diseaseSever’s diseaseOsteochondritis dissecansOsteochondritis dissecansOsteochondritis dissecansOsteochondritis dissecansSlipped Capital Femoral Epiphysis (SCFE)Slipped Capital Femoral Epiphysis (SCFE)Tarsal coalitionTarsal coalitionScoliosisScoliosis

Observations During MSK ExamObservations During MSK ExamGeneral habitusGeneral habitusGait/stanceGait/stanceGait/stanceGait/stanceJoint Range of Motion Joint Range of Motion Swelling, tenderness and/or pain with motionSwelling, tenderness and/or pain with motionSymmetrySymmetry

Skin foldsSkin foldsLimb lengthLimb lengthLimb lengthLimb lengthAtrophyAtrophy

Tendonitis Tendonitis StrengthStrength

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Observe ADL’s during exam

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Important ConsiderationsImportant Considerations

Generalized growth disturbancesGeneralized growth disturbancesLinear growthLinear growthWeightWeightBone healthBone healthSkeletal growthSkeletal growthNutrition (protein energy malnutrition)Nutrition (protein energy malnutrition)Delay in sexual maturationDelay in sexual maturation

Localized growth disturbances in rheumatic diseasesLocalized growth disturbances in rheumatic diseasesoca ed g o t d stu ba ces eu at c d seasesoca ed g o t d stu ba ces eu at c d seasesLimb length discrepanciesLimb length discrepanciesJaw MicrognathiaJaw Micrognathia

Systematically Review Aspects Systematically Review Aspects of Musculoskeletal System in of Musculoskeletal System in

Children/AdolescentsChildren/Adolescents

CC--spinespineTMJ’sTMJ’sHands & wristsHands & wrists

HipsHipsKneesKneesAnkles, subtalar, & Ankles, subtalar, &

Elbows Elbows ShouldersShoulders

feetfeetSpine Spine ---- thoracic and thoracic and lumbosacrallumbosacral

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Cervical SpineCervical Spine

• Extension

• Flexion

• Extension

• Rotation

• Lateral Flexion

JIA & Cervical SpineJIA & Cervical Spine

•More common in polyarticular/systemic JIA

•Occiput at level of 1st

thoracic vertebrae

•Rule of thumb: 10o flexion restriction = 1 finger b/w chin and chest alland chest wall

•Concern: Atlantoaxial instability

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Children with arthritis Children with arthritis can also developcan also developcan also develop can also develop torticollistorticollisCan be a manifestation Can be a manifestation of cervical spine of cervical spine involvement ORinvolvement ORIdiopathic shortening ofIdiopathic shortening ofIdiopathic shortening of Idiopathic shortening of a sternocleidomastoid a sternocleidomastoid musclemuscle

Temporomandibular JointTemporomandibular Joint

Oral appatureOral appatureNormalNormal >> 40 mm or 340 mm or 3Normal Normal >> 40 mm or 3 40 mm or 3 finger widthsfinger widths

PalpationPalpationPlace forefinger in Place forefinger in external auditory canal external auditory canal ORORPlace tip forefinger Place tip forefinger anterior to external anterior to external auditory meatusauditory meatus

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Temporomandibular ArthritisTemporomandibular Arthritis

Finding can be subtle Finding can be subtle ––occurs insidiously; canoccurs insidiously; canoccurs insidiously; can occurs insidiously; can “sneak up”“sneak up”Up to 55% depending on Up to 55% depending on studystudyAnterior viewAnterior view----jaw jaw deviates to involved sidedeviates to involved sideOften seen or noted at Often seen or noted at times of skeletal growthtimes of skeletal growthtimes of skeletal growthtimes of skeletal growthLead to problems with Lead to problems with malocclusionmalocclusionObserve lateral viewObserve lateral view

MicrognathiaMicrognathia

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HandsHands

Supination

Pronation

Overall swelling

Th t hThenar atrophy

HandsHands

Should be able to k f ll fi tmake full fist

Need to determine whether loss of full flexion due to:

• MCP involvement

• PIP involvement

• DIP involvement

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WristsWrists

Extension

• 90 degrees

Flexion

• 90 degrees

ElbowsElbows

Anatomical

Flexion /Extension

Check for:

landmarks

joint swelling contractures rheumatoid nodules epitrochlear nodes

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Limb Length DiscrepancyLimb Length Discrepancy

E l i diE l i diEarly in disease course Early in disease course —— extremity may exhibit extremity may exhibit overgrowth or be longerovergrowth or be longer

Late in disease course Late in disease course —— extremity ends up extremity ends up y py pshortershorter

Ulnar vs. radial driftUlnar vs. radial drift

ShouldersShoulders

Active ROMActive ROMActive ROMActive ROM

Can be helpful in Can be helpful in assessing ability to assessing ability to perform ADLperform ADL

Younger children Younger children “Simon Says”“Simon Says”

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ShoulderShoulder

Extension Flexion

Landmarks

External rotation / (Internal rotation)

ABduction

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HipsHips

Patrick testPatrick test

FlexionFlexion Extension w/ abductionExtension w/ abduction

Hamstring tightnessHamstring tightnessPatrick testPatrick test Hamstring tightnessHamstring tightness

Hips (con’t.)Hips (con’t.)

External rotation

Internal rotation

Internal rotation / prone

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Maneuvers to Assess the HipManeuvers to Assess the Hip

Trendelenburg signTrendelenburg signThomas testThomas test

Gaenslen’s testGaenslen’s test

KneesKnees

Flexion Extension

Prone lyingProne lyingContractureContractureSymmetry of calvesSymmetry of calvesYounger childrenYounger children

•• Symmetry of Symmetry of skin foldsskin folds

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Epiphyseal overgrowth Epiphyseal overgrowth secondary to inflammationsecondary to inflammation

Bony OvergrowthBony Overgrowth

Valgus deformityValgus deformity

Baker’s CystBaker’s CystPosterior / pronePosterior / prone

Baker’s cystBaker’s cyst

Baker s CystBaker s Cyst

Limb Length DiscrepancyLimb Length Discrepancy

Limb length discrepancyLimb length discrepancyg p yg p yMeasure from superior iliac Measure from superior iliac crest to medial malleoluscrest to medial malleolus

Limb length discrepancyLimb length discrepancyGaleazzi testGaleazzi test

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Examination Maneuvers to Examination Maneuvers to Assist in Etiology of SymptomsAssist in Etiology of Symptoms

Patellar apprehension/compression testPatellar apprehension/compression test

McMurray test McMurray test ------ used to evaluate meniscal injury used to evaluate meniscal injury

Apley compression test Apley compression test ------ used to evaluate meniscal injuryused to evaluate meniscal injury

Lachman test or Anterior Drawer Sign Lachman test or Anterior Drawer Sign ------ used to evaluate ACL injuryused to evaluate ACL injury

Pain with compression of the infrapatellar tendonPain with compression of the infrapatellar tendon——Jumper’s kneeJumper’s knee

Pain with compression over inferior pole of the patellaPain with compression over inferior pole of the patella——SindingSinding--LarsenLarsen--Johansson disease Johansson disease

Pain with compression over tibial tubercle Pain with compression over tibial tubercle ------ Osgood Schlatter’sOsgood Schlatter’s

West S. Rheumatology Secrets, 2West S. Rheumatology Secrets, 2nd nd edition, Philadelphia, Hanley & Belfus Inc. 2002; 451edition, Philadelphia, Hanley & Belfus Inc. 2002; 451--452, 488.452, 488.

Patellar Compression Patellar ApprehensionPatellar Apprehension

Evaluation Patellar Area

Patellar Compression Test

Patellar Apprehension Patellar Apprehension TestTest

Weiner DS. and Jones K. Patelofemoral Pain Syndrome. In: Pediatric Orthopedics for Primary Care Physicians, 2nd edition, Cambridge University Press, Cambridge, 2004; 95-97.

Patellar apprehension

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Patellofemoral Syndrome (PFS) Patellofemoral Syndrome (PFS) in Children/Adolescentsin Children/Adolescents

Probably accounts for greatest number of all cases of Probably accounts for greatest number of all cases of knee pain seen in adolescentsknee pain seen in adolescentsMore common in femalesMore common in femalesPain is always of a mechanical naturePain is always of a mechanical natureAbnormal patellar tracking, muscle units, ligamentous Abnormal patellar tracking, muscle units, ligamentous status and osseous structuresstatus and osseous structuresstatus and osseous structuresstatus and osseous structures

Common Findings on Physical Common Findings on Physical ExaminationExamination

↑ p↑ patellar mobilityatellar mobility+ p+ patellar apprehension sign atellar apprehension sign ––used to assess patellar injury or used to assess patellar injury or dislocationdislocationPatellar facet tendernessPatellar facet tendernessPatellar tendon tenderness and infrapatellar compartmentPatellar tendon tenderness and infrapatellar compartment ↓ ↓ muscle bulk & weakness of vmuscle bulk & weakness of vastus medialisastus medialisWeak hip flexors/tight hamstringsWeak hip flexors/tight hamstrings+ p+ patellar compression testatellar compression test p patellar compression testatellar compression testGrating, clicking, catching, “Giving out”Grating, clicking, catching, “Giving out”

Malleson PN and Sherry DD. Noninflammatory Musculoskeletal Pain Conditions. In: Cassidy JT, Petty RE, et Malleson PN and Sherry DD. Noninflammatory Musculoskeletal Pain Conditions. In: Cassidy JT, Petty RE, et al. al. Textbook of Pediatric RheumatologyTextbook of Pediatric Rheumatology, 5, 5thth edition, Philadelphia, Elsevier Inc. 2005; 680.edition, Philadelphia, Elsevier Inc. 2005; 680.

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McMurray TestMcMurray Test

Maneuvers to Evaluate Meniscus

McMurray test

Apley TestApley Test

McMurray test

Apley Maneuver

Maneuver to Evaluate Anterior Cruciate Ligament

Lachman TestLachman Test

Lachman test

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Feet and AnklesFeet and Ankles

• Dorsiflexion • Plantar flexion

Feet and Ankles (con’t.)Feet and Ankles (con’t.)

•Medial rotation •Lateral rotation

•MTP’s & Toes

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Assess prone lying

• soles of feet

Feet and Ankles (con’t.)Feet and Ankles (con’t.)

Assess for enthesitis

• tight achilles

Symmetry of calves

• Assess hips, knees, ankles all at once---”Duck Walk”

SpineSpine• Lumbar Flexion • Lateral Flexion • Lumbar Extension

• Schober’s • Modified Schober’s

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Joint HypermobilityJoint Hypermobility

Joint HypermobilityJoint Hypermobility

The ability to The ability to painlesslypainlessly perform the following perform the following five maneuvers…five maneuvers…

Passive apposition Passive apposition of thumb to of thumb to forearmforearm

Passive Passive hyperextension hyperextension ypypof fingersof fingers(5(5thth finger can finger can parallel forearm)parallel forearm)

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Active Active hyperextension hyperextension of elbow >10 degreesof elbow >10 degrees

Active Active hyperextension of hyperextension of knee >10 degreesknee >10 degrees

Ability to flex spine and place palms to floor without bending knees

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The Beighton Diagnostic/Scoring The Beighton Diagnostic/Scoring CriteriaCriteria

Specific Joint LaxitySpecific Joint Laxity RightRight LeftLeft

P i iti f th bP i iti f th bPassive apposition of thumb Passive apposition of thumb to forearm 1 1to forearm 1 1

Passive hyperextension of fingers 1 Passive hyperextension of fingers 1 11

Active hyperextension of elbow Active hyperextension of elbow >10 degrees>10 degrees 11 11

Active hyperextension of knee Active hyperextension of knee >10 degrees>10 degrees 11 11

Ability to flex spine and place palms Ability to flex spine and place palms to floor without bending kneesto floor without bending knees 11

__________________________________

4 4 + + 1 1 + + 4 = 94 = 9

Beighton PH & Horan FT. Dominant inheritance in familial generalized articular Beighton PH & Horan FT. Dominant inheritance in familial generalized articular hypermobility. hypermobility. Journal of Bone and Joint Surgery British 1970; 52 (1): 145Journal of Bone and Joint Surgery British 1970; 52 (1): 145--147.147.

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Specific Muscle/Myofascial Specific Muscle/Myofascial Assessment in Assessment in

Children and AdolescentsChildren and Adolescents

Myofascial tendernessMyofascial tenderness

Muscle strength, atrophy, symmetryMuscle strength, atrophy, symmetry•• Manual Muscle Testing (MMT)Manual Muscle Testing (MMT)•• Childhood Myositis Assessment ScaleChildhood Myositis Assessment Scale•• Childhood Myositis Assessment ScaleChildhood Myositis Assessment Scale

All evaluations should be developmentally/functionally based assessments

Tender Point LocationsTender Point LocationsBase of occiputBase of occiput----insertion of musclesinsertion of musclesTrapeziusTrapezius--upper border mid portionupper border mid portionTrapeziusTrapezius upper border mid portionupper border mid portionMuscle attachments to upper medial border scapulaMuscle attachments to upper medial border scapulaAnterior aspect of C5, C7 interAnterior aspect of C5, C7 inter--transverse spacestransverse spacesSecond rib space about 3 cm to sternal borderSecond rib space about 3 cm to sternal borderLateral epicondyleLateral epicondyle——2 cm below bony prominence2 cm below bony prominenceGluteal musclesGluteal muscles——upper outer quadrantupper outer quadrantGreater trochanterGreater trochanter 1 cm posterior to insertion of1 cm posterior to insertion ofGreater trochanterGreater trochanter——1 cm posterior to insertion of 1 cm posterior to insertion of musclesmusclesMedial fat pad of kneeMedial fat pad of knee——1 cm proximal to joint line1 cm proximal to joint line

Wolfe F, et al. Wolfe F, et al. Arthritis and Rheumatism; Arthritis and Rheumatism; 1990 33 (2): 1601990 33 (2): 160--172.172.

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Tender Point DiagramTender Point Diagram

Yunus MB, Masi AT. Juvenile Primary Fibromyalgia Syndrome A Clinical Study of Thirty-Three Patients and Matched Normal Controls. Arthritis and Rheumatism; 28 (2): 138145. (pending permission)

Juvenile Primary Fibromyalgia Juvenile Primary Fibromyalgia Syndrome: Diagnostic CriteriaSyndrome: Diagnostic CriteriaMajor criteriaMajor criteria

Generalized musculoskeletal aching at 3 or more sites for 3 or Generalized musculoskeletal aching at 3 or more sites for 3 or more monthsmore monthsAbsence of underlying condition or causeAbsence of underlying condition or causeLaboratory tests normalLaboratory tests normalPain in 5 or more tender points Pain in 5 or more tender points (4kg of pressure)(4kg of pressure)

Minor criteriaMinor criteriaMinor criteria Minor criteria

3/10 criteria 3/10 criteria

Yunus, MB, Masi AT. Yunus, MB, Masi AT. Arthritis RheumArthritis Rheum 1985; 28 (2): 1381985; 28 (2): 138--145145

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Juvenile Primary Fibromyalgia Juvenile Primary Fibromyalgia Syndrome: Diagnostic CriteriaSyndrome: Diagnostic Criteria

Minor CriteriaMinor Criteria 3/103/10Minor CriteriaMinor Criteria------3/103/10Poor sleepPoor sleepFatigueFatigueChronic anxiety or tension Chronic anxiety or tension Chronic headachesChronic headachesIrritable bowel syndromeIrritable bowel syndromeSubjective soft tissue swellingSubjective soft tissue swellingNumbnessNumbnessPain modulated by: Pain modulated by:

--physical activity, weather, anxiety/stress physical activity, weather, anxiety/stress

Yunus, MB, Masi ATYunus, MB, Masi AT. Arthritis Rheum. Arthritis Rheum 1985; 28 (2): 1381985; 28 (2): 138--145.145.

Manual Muscle TestingManual Muscle TestingMuscle/muscle groups ability to isometrically Muscle/muscle groups ability to isometrically “hold” or resist an applied force“hold” or resist an applied forceGrading/scoring scaleGrading/scoring scaleGrading/scoring scaleGrading/scoring scale

•• 5/55/5 = = NormalNormal Full resistance against gravityFull resistance against gravity•• 4/5 = 4/5 = GoodGood Partial resistance against gravityPartial resistance against gravity•• 3/5 = 3/5 = FairFair Unable to provide resistance Unable to provide resistance

against gravityagainst gravity•• 2/5 =2/5 = PoorPoor No movement against gravityNo movement against gravity•• 2/5 2/5 PoorPoor No movement against gravityNo movement against gravity•• 1/5 = 1/5 = TraceTrace Only slight muscle contraction Only slight muscle contraction

(no joint movement)(no joint movement)•• 0/5 = 0/5 = Zero Zero No muscle activityNo muscle activity

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M l M l T ti CM l M l T ti CManual Muscle Testing Can Manual Muscle Testing Can NOT Be Used in Younger NOT Be Used in Younger

ChildrenChildren

Childhood Myositis Childhood Myositis Assessment Scale (CMAS)*Assessment Scale (CMAS)*

Validated and quantitative, observational instrument Validated and quantitative, observational instrument q ,q ,for composite assessment of:for composite assessment of:

strengthstrengthfunctionfunctionEnduranceEndurance

14 physical maneuvers14 physical maneuvers

Scores range from 0Scores range from 0--5252

Points are awarded according to the descriptor that Points are awarded according to the descriptor that best fits the patient’s performance of the maneuverbest fits the patient’s performance of the maneuver

*Lovell DJ, et al. Development of Validated Disease Activity and Damage Indices for the Juvenile Idiopathic Inflammatory Myopathies, Arthritis Rheum 1999; 42: 2213-2219.

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Correlation ofCorrelation of CMAS Scores*CMAS Scores*MD Global (VAS) r2 = 0.357 P = 0.05

MMT 2 0 88 P 0 001MMT score r2 = 0.88 P = 0.001

Serum CK level r2 = 0.40 P = 0.004

JAFAR score r2 = 0.70 P < 0.001

P d i d 2 0 61 P 0 008Prednisone dosage r2 = 0.61 P = 0.008

*Lovell DJ, et al. Development of Validated Disease Activity and Damage Indices for Juvenile Idiopathic Inflammatory Myopathies. Arthritis Rheum 1999; 42: 2213-2219.

CMAS: 14 MANEUVERSCMAS: 14 MANEUVERS

11 Head liftHead lift 8 Arm lift/duration8 Arm lift/duration1.1. Head liftHead lift 8. Arm lift/duration8. Arm lift/duration2.2. Leg lift/touchLeg lift/touch 9. Floor Sit9. Floor Sit3.3. Leg lift/durationLeg lift/duration 10. All Fours10. All Fours4.4. SupineSupine--ProneProne 11. Floor Rise11. Floor Rise5.5. SitSit--upsups 12. Chair Rise12. Chair Rise6.6. SupineSupine--SitSit 13. Stool Step13. Stool Step7.7. Arm lift/straightArm lift/straight 14. 14. PickPick--upup

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Head LiftHead Lift

Timed maneuverTimed maneuverTimed maneuverTimed maneuverSupine positionSupine positionOcciput off the tableOcciput off the tableMaximum 2 minutesMaximum 2 minutesScore from 0Score from 0--55

Arm Raise/StraightenArm Raise/StraightenPerformed in seated Performed in seated positionpositionLevel of wrists is keyLevel of wrists is keyLevel of wrists is key Level of wrists is key measurement factormeasurement factorScore from 0Score from 0--33

Arm Raise/DurationArm Raise/Duration►► Timed maneuverTimed maneuver ►► Maximum of 60 secondsMaximum of 60 seconds►► Raise arms simultaneouslyRaise arms simultaneously ►► Score from 0Score from 0--44►► Wrists should be in highest Wrists should be in highest

position possibleposition possible

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Leg Raise/Touch ObjectLeg Raise/Touch Object

Supine positionSupine positionDistance of 2 “patient foot Distance of 2 “patient foot lengths”lengths”lengths”lengths”Score from 0Score from 0--22

Straight Leg Lift/DurationStraight Leg Lift/Durationg gg g

►► Timed maneuverTimed maneuver ►► Knee extensionKnee extension►► Supine position Supine position ►► Maximum of 2 minutesMaximum of 2 minutes►► Distance of 1 “patient foot length” Distance of 1 “patient foot length” ►► Score from 0Score from 0--55

Supine to ProneSupine to Prone

Torso and shoulderTorso and shoulderTorso and shoulder Torso and shoulder strengthstrengthRight arm flexedRight arm flexedRoll over to prone Roll over to prone positionpositionPulls right arm outPulls right arm outPulls right arm out Pulls right arm out from under torsofrom under torsoScore from 0Score from 0--33

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Supine to SitSupine to Sit

Torso strengthTorso strengthTorso strengthTorso strengthEndpoint: legs dangle Endpoint: legs dangle freely over tablefreely over tableMay use hands or May use hands or armsarmsS f 0S f 0 33Score from 0Score from 0--33

Floor Sit & Floor RiseFloor Sit & Floor Rise

Initiate in standing positionInitiate in standing positionDescend into sitting positionDescend into sitting positiong pg pDone with/without support (part Done with/without support (part of criteria for scoring)of criteria for scoring)Score from 0Score from 0--33

Begins seated on floorBegins seated on floorRise to kneeling on both kneesRise to kneeling on both kneesRise to kneeling on both kneesRise to kneeling on both kneesRaise left knee in front with foot Raise left knee in front with foot on floor (hip and knee at 90 on floor (hip and knee at 90 degrees flexion)degrees flexion)Rise from kneeling to standingRise from kneeling to standingScore from 0Score from 0--44

** Watch for Gower signWatch for Gower sign

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All Four ManeuversAll Four Maneuvers

Begins in prone positionBegins in prone positionBegins in prone positionBegins in prone positionRise to crawling positionRise to crawling positionCrawl (creep) forwardCrawl (creep) forward——all 4 weight bearing all 4 weight bearing points must end in new points must end in new positionpositionpositionpositionExtension of right legExtension of right legScore from 0Score from 0--44

Chair RiseChair Rise

Seated in armless Seated in armless chair (agechair (agechair (agechair (age--appropriate size)appropriate size)Lower legs Lower legs perpendicular to floorperpendicular to floorRise to standRise to standS f 0S f 0 44Score from 0Score from 0--44

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SitSit--Ups:Ups:•• Total of 6 sitTotal of 6 sit--upsups•• 3 sit3 sit--ups with counterbalanceups with counterbalance•• 3 sit3 sit--ups without counterbalanceups without counterbalance•• Score from 0Score from 0--6 6

Stool StepStool Step•• Step up approximately 7Step up approximately 7--8 inches8 inches•• Done without supportDone without support•• Observe for absence/presence of Gower signObserve for absence/presence of Gower sign•• Score from 0Score from 0--33

Pick UpPick UpPick UpPick Up•• Begin in standing positionBegin in standing position•• Bend over and pick up pen/pencilBend over and pick up pen/pencil•• Return to erect standing positionReturn to erect standing position•• Score from 0Score from 0--33

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Measures of Pediatric FunctionChildhood health Assessment Questionnaire (CHAQ)

Juvenile Arthritis Functional Assessment Report (JAFAR)

Juvenile Arthritis Functional Assessment Scale (JAFAS)

Juvenile Arthritis Functional Assessment Index (JASI)

Chronic Activity Limitations Scale (CALS)

Pediatric Orthopedic Surgeons of North America (POSNA) Pediatric Musculoskeletal Functional Health Questionnaire

Arthritis Care & Research 2003; 49 (5) Supplement

Measures of Pediatric Pain and Quality of Life

Pain Behavior Observation Methods

P i C i Q ti i (PCQ)Pain Coping Questionnaire (PCQ)

Pediatric Pain Questionnaire (PPQ)

Juvenile Arthritis Quality of Life Questionnaire (JAQQ)

Pediatric Quality of Life (PedsQL)

Fibromyalgia (Modified) Impact Questionnaire (FIQ)

Arthritis Care & Research 2003; 49 (5) Supplement

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When I approach a child, they When I approach a child, they inspire in me two sentiments: inspire in me two sentiments:

tenderness for what they are, and tenderness for what they are, and respect for what they may become.respect for what they may become.

----Louis PasteurLouis Pasteur

THANK

YOU!