ormative Reference Values

for Musculoskeletal Conditions and Functional Motor

Abilities in the Pediatric Population
Literature Review and Clinical Guidelines

Anne Parrot
© IRDPQ - 2010

Pediatric physical therapist

Collaborators:
Michel Tousignant
Director of Physical Therapy Program
Yvan St-Cyr
Orthopedic surgeon
Introduction - http://www.irdpq.qc.ca/communication/publications/PDF/Preliminaries.pdf

Part 1 – Gait : http://www.irdpq.qc.ca/communication/publications/PDF/Part_1_Gait.pdf

Part 2 – Muscle Strength and Physical Fitness :

http://www.irdpq.qc.ca/communication/publications/PDF/Part_2_Muscle.pdf

Part 3 – Range of Motion : http://www.irdpq.qc.ca/communication/publications/PDF/Part_3_Range.pdf

Part 4 – Specific Tests : http://www.irdpq.qc.ca/communication/publications/PDF/Part_4_Specific.pdf

Part 5 – The Foot : http://www.irdpq.qc.ca/communication/publications/PDF/Part_5_Foot.pdf

Normative Reference Values
for Musculoskeletal Conditions and Functional
Motor Abilities in the Pediatric Population

ANNE PARROT
Pediatric physical therapist
Institut de réadaptation en déficience physique de Québec

Collaborators
MICHEL TOUSIGNANT
Director of the Physical therapy program of the Faculty of Medicine, and of
Health Sciences, University of Sherbrooke

YVAN ST-CYR
Orthopedic Surgeon
Centre Hospitalier de l’Université Laval
Professor of orthopedics at the Faculty of Medicine at Laval University
 INSTITUT DE RÉADAPTATION EN DÉFICIENCE PHYSIQUE DE QUÉBEC
525, boul. Wilfrid-Hamel
Québec (Québec) G1M 2S8

Copyright © 2009 by Institut de réadaptation en déficience physique de Québec

All rights reserved. This book is protected by copyright. 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 written permission from the publisher.

ISBN : 978-2-922242-44-7
e
Dépôt légal 4 trimestre 2009.
Bibliothèque Nationale du Québec
Bibliothèque Nationale du Canada

Puisque toutes les études sélectionnées et retenues de la revue de littérature pédiatrique étaient publiées
en anglais, les études et leurs résultats respectifs sont donc présentés dans la langue d’origine afin
d’éviter la traduction et la validation de chaque outil de mesure.

This document was produced in English as all the selected studies obtained through the pediatric literature
review were published in this language. The studies and their respective results are therefore presented in
their original language in order to avoid the translation and the validation of each measurement tool.
 Ce livre est dédié à tous ces enfants et familles
extraordinaires que nous côtoyons en réadaptation pédiatrique.

This manual is dedictated to all the exceptional children and families

seen in pediatric rehabilitation.
 Normative References Values for Musculoskeletal Conditions and Functional Motor Abilities in the Pediatric Population v

This reference manual is the collaborative work of Anne Parrot, pediatric physical therapist, Dr Michel
Tousignant, scientific researcher and Dr Yvan St-Cyr, pediatric orthopedist. Ms Parrot is the author of the
document.

Ms. Anne Parrot is a physical therapist who has been working with children with different kinds of disabilities
for over twenty-nine years at the Institut de réadaptation en déficience physique de Québec (IRDPQ). She
has extensive experience in clinical work, continuing education and teaching. She has actively participated in
different research studies and scientific articles.

Michel Tousignant, PT, PhD is the Director of the Physical Therapy Program of the Faculty of Medicine, and
of Health Sciences, Université de Sherbrooke. Mr. Tousignant has a background in research methodology
and many research studies and published scientific articles to his account.

Doctor Yvan St-Cyr is an orthopedic surgeon of over 30 years experience. He is actively engaged at the
Centre Mère Enfant of the CHUL (Centre Hospitalier of l’Université Laval) and acts as a consulting physician
for many pediatric rehabilitation centers in the province of Quebec. He is currently professor of orthopedics at
the Faculty of Medicine at Université Laval. He has authored many clinical presentations in the field of
pediatric orthopedics.
 Normative References Values for Musculoskeletal Conditions and Functional Motor Abilities in the Pediatric Population vii

Acknowledgments

The authors would like to thank the directors of the Institut de réadaptation en déficience physique de Québec
(IRDPQ) who financially supported this project.

We address special thanks to Ms Johanne Trahan, Head of the Knowledge Management Service for her
encouragement and support at all times through the development of this project.

We acknowledge the contribution of Mr Mario Cloutier, Head of the Traumatic Brain Injury Program and Ms
Aline Carrier, Ms Isabelle Larouche and Ms Julie Beaulieu, Ms Caroline Dubois, Heads of the School
Integration and Rehabilitation program for children with motor impairments.

The authors recognize and thank many collaborators from the IRDPQ for their dedication and participation in
this project:

The library technicians for their patience and rapid search capability.

The Knowledge Management Service.

Annick Girard, physical therapist, for her assistance with the preparation of the manuscript. She
revised the clinical aspects of each outcome measure to insure that the data was easily accessible to
the clinicians.

Chantal Ferland, physical therapist, for her help in demonstrating different measurement techniques
used in our illustrations.

Marc Pilon. MSc. c.o. (c) Orthotist-prosthetist, for his help in providing and adapting certain
measurement tools.

We also thank other important collaborators:

Our models: Daniel Parrot-Mainville, Ludovick St Pierre, Rosalie Albert, Xavier Bleau, Florence
Moreau-Trahan, and their parents.

Henriette Patenaude, Robert Patenaude, Rita Patenaude, David and Simone Marcantel for editing
the text.

Marie-Lyne Benoît, occupational therapist, for revising the grip strength section.
 Normative References Values for Musculoskeletal Conditions and Functional Motor Abilities in the Pediatric Population ix

Contents

INTRODUCTION ................................................................................................................................................... xii

Research Methodology ....................................................................................................................................... xiii
Search Results .................................................................................................................................................... xiv
The reference manual .......................................................................................................................................... xv
CONCLUSION .................................................................................................................................................... xvii
References ........................................................................................................................................................ xviii

PART 1: GAIT
Summary ............................................................................................................................................................... 2
1. The Footprint Method – Assessment of Spatial Gait Parameters..................................................................... 6
2. Distance Walk Test – Gait Velocity and Cadence – Indoor .............................................................................. 9
3. Distance Walk Test – Gait Velocity and Cadence – Outdoor ......................................................................... 15
4. Distance Walk Test – Gait Velocity in a School Setting .................................................................................. 20
5. Functional Ambulatory Mobility Test – Timed ‘Up and Go’ Test in Children .................................................. 23
6. Timed-Walk Test – Six Minute Walk Test – Outdoor ...................................................................................... 29
7. Timed-Walk Test – Thirty-Second Walk Test – Indoor ................................................................................... 34

References .......................................................................................................................................................... 38
Annex : Up to Date References .......................................................................................................................... 41

PART 2: MUSCLE STRENGTH AND PHYSICAL FITNESS

Summary ............................................................................................................................................................. 47
Assessment of Strength through Functional Motor Activities..................................................................... 47
1. Timed Performance Tests ............................................................................................................................... 48
2. Childhood Myositis Assessment Scale-9 ....................................................................................................... 52

Assessment of Muscle Strength with the Hand-Held Dynamometer

3. Summary ......................................................................................................................................................... 63
4. Maximum Isometric Muscle Torque – Make Test Technique ......................................................................... 67
5. Maximum Isometric Muscle Force – Make Test Technique ........................................................................... 74
6. Maximum Isometric Muscle Force – Break Test Technique ........................................................................... 80
7. Hand Grip Strength-Summary......................................................................................................................... 85
A) Assessment with the Jaymar Hand-Held Dynamometer ........................................................................... 85
B) Assessement with the Lafayette Pediatric Hand-Held Dynamometer....................................................... 90

Trunk Muscle Strength

Summary ........................................................................................................................................................... 94
8. Trunk Flexor Muscle Strength ......................................................................................................................... 94

Health-Related Fitness Batteries

Summary ........................................................................................................................................................... 100
9. The President’s Challenge Physical Fitness Awards .................................................................................... 102

References .......................................................................................................................................................... 104

Annex : Up to Date References .......................................................................................................................... 109

PART 3: RANGE OF MOTION

Summary ............................................................................................................................................................ 115
1. Passive Range of Motion in the Premature Child ......................................................................................... 117
2. Passive Range of Motion of the Hip in the Newborn .................................................................................... 122
3. Passive Range of Motion of Hip Rotations in Prone Position in Infants ....................................................... 128
x Normative References Values for Musculoskeletal Conditions and Functional Motor Abilities in the Pediatric Population

4. Passive Range of Motion of the Ankle in the Newborn ................................................................................. 132

5. Active Range of Motion in the Upper Extremities in Male Subjects .............................................................. 136
6. Active Range of Motion in the Upper Extremities ......................................................................................... 140
7. Active and Passive Range of Motion in the Shoulder ................................................................................... 144
8. Active Range of Motion in the Lower Extremities in Male Subjects .............................................................. 148
9. Active Range of Motion in the Lower Extremities ........................................................................................ 152
10. Passive Range of Motion in the Lower Extremities ...................................................................................... 155
11. Passive Range of Motion of the Ankle ........................................................................................................ 165
12. Passive Range of Motion of Ankle Dorsiflexion in Adolescent Athletes ....................................................... 169

References .......................................................................................................................................................... 172

Annex : Up to Date References .......................................................................................................................... 175

PART 4: SPECIFIC TESTS

Hip Flexion Contracture
Summary ............................................................................................................................................................. 181
1. Hip Flexion Contracture in the Premature Child ........................................................................................... 182
2. Hip Flexion Contracture in the Newborn ....................................................................................................... 186
3. Hip Flexion Contracture in Infants ................................................................................................................ 190
4. Hip Flexion Contracture in Children ............................................................................................................. 194

Knee Flexion Contracture

Summary ............................................................................................................................................................. 198
5. Knee Flexion Contracture in the Newborn .................................................................................................... 199
6. Knee Flexion Contracture in Newborns and Infants .................................................................................... 203
7. Knee Flexion Contracture in Children ........................................................................................................... 206

Hamstring Tightness Assessment

Summary .......................................................................................................................................................... 209
8. The Popliteal Angle ....................................................................................................................................... 210
9. The Popliteal Complimentary Angle ............................................................................................................. 217
10. Straight Leg Raise Test ................................................................................................................................ 222

Rotational Profile in the Lower Extremities

Summary ............................................................................................................................................................ 227
11. Foot Progression Angle................................................................................................................................. 228
12. Lateral Hip Rotation and Medial Hip Rotation ............................................................................................... 231
13. Thigh-Foot Angle and the Transmalleolar Axis-Thigh Angle ........................................................................ 234
14. Forefoot Alignment: Metatarsus Adductus .................................................................................................... 241

Tibial Torsion
Summary ............................................................................................................................................................ 244
15. Measurement of the Transmalleolar Axis, Knee in Flexion .......................................................................... 244
16. Measurement of the Transmalleolar Axis, Knee in Extension ...................................................................... 250

Genu Valgum and Genu Varum

Summary ............................................................................................................................................................ 254
17. Intercondylar and Intermalleolar Distances in Supine ................................................................................. 256
18. Tibiofemoral Angle, Intercondylar and Intermalleolar Distances in Supine and Standing ............................ 260
19. Tibiofemoral Angle, Intercondylar and Intermalleolar Distances in Standing ............................................... 265

Joint Hypermobility
Summary ............................................................................................................................................................ 271
20. Beighton Score Index .................................................................................................................................... 273
21. Lower Limb Assessment Score..................................................................................................................... 278

References .......................................................................................................................................................... 282

 Normative References Values for Musculoskeletal Conditions and Functional Motor Abilities in the Pediatric Population xi

Annex : Up to Date References .......................................................................................................................... 287

PART 5: THE FOOT

Summary ............................................................................................................................................................ 295
1. Footprint Analysis – Staheli’s Arch Index ........................................................................................................ 298
2. Anthropometric Measurements – Navicular Height ........................................................................................ 304
3. Anthropometric Measurements – Relaxed Calcaneal Stance Position .......................................................... 307

References .......................................................................................................................................................... 312

Annex : Up to Date References .......................................................................................................................... 314
xii Normative References Values for Musculoskeletal Conditions and Functional Motor Abilities in the Pediatric Population

Introduction

Child development is a dynamic process which makes pediatric assessments a constant challenge. Ongoing
neuro-developmental maturation and physiologic musculoskeletal changes present many variations in the
healthy child and therefore it is important to take into consideration function and anatomy with regard to age,
gender and cultural specificities. Many scientific studies have analyzed these normal variations in order to
define what is considered “the limits of normal”. These limits are defined as age normative reference values
and are of interest to the healthcare professionals involved in diagnosing, monitoring or treating children with
disabilities.

There are many advantages in using pediatric normative data as they provide guidelines for normal growth
and development, set a basis for management and can be used as reminders for future observations in
follow-ups. The data can also help to draw conclusions about changes in symptoms over time.
However, in order to be able to use the normative data as a means of comparison between the child with
disabilities and the healthy child, the clinician needs to take into consideration the testing procedures of the
method used to document the condition. Also, it is important to consider the strength and limits of the
research study that analyzed the assessment tool (Number of subjects, validity, reliability…).

During the last decade, the demand for outcome measures and documentation has increased in clinical
2, 3 3
practice. However, as cited by Majnemer et al. (2002) “…outcome determination in the field of pediatric
rehabilitation is challenged by a lack of availability of sound instruments that are appropriate across age
groups from infancy to adolescence…”.
8
As defined by the Canadian Physiotherapy Association (2006) “…best current research findings are provided
by external evidence produced by clinically relevant research. Best current research findings can be provided
by clinical practice guidelines, systematic reviews, randomized and controlled clinical trials, observational
studies and case reports…”. However, the access to the scientific data can be a challenge due to the vast
amount of research reports published through the years by different means of communication. In everyday
practice, the time needed to search for various pediatric studies is not always accessible to the clinicians. To
address this challenge, a project was developed and put forward with the following objectives:

1. To review the pediatric scientific literature for clinically relevant research providing normative
reference values obtained by easily implemented measurement tools in clinical practice.

2. To produce a reference manual presenting a compilation of the findings with normal baseline values
and clinical practice guidelines for various musculoskeletal conditions and functional motor abilities.
 Normative References Values for Musculoskeletal Conditions and Functional Motor Abilities in the Pediatric Population xiii

Research Methodology

The pediatric scientific literature was reviewed for norm-referenced tests, appropriate for use with children
from birth to 18 years of age. Norm-referenced tests are defined as “…measures that have been tested on a
representative sample of the population of interest, typically a non-disabled population representing the ages,
7
genders, environments, etc., of the people for whom the test was designed.”

SEARCH STRATEGY
Focal points in the review centered around five topics:
1) Gait;
2) Muscle strength and physical fitness;
3) Range of motion;
4) Specific tests;
5) The foot.

The review covered the period from 1972 to 2006.

A key word search conducted in the following electronic databases: PUBMED, EMBASE CINAHL
ERIC and BIOSIS PREVIEW was used to query the following: children, validity, reliability, norms,
assessment, outcome measures. These key words were combined to specific key words
representing each topic such as:
1) Endurance, speed, community for gait;
1) Strength, grip, trunk, fitness for muscle strength and physical fitness;
2) Joint motion, lower extremities, upper extremities for range of motion;
3) Torsion, hypermobility, hypomobility, contracture, toeing-in for specific tests;
4) Alignment, arch for the foot.

The electronic review was performed by the library technician of the IRDPQ and by the pediatric
physical therapist.

Additional sources were Google and Copernic search engines. The reference lists of all the selected
articles obtained by the electronic search were also scanned by the physical therapist to verify if any
tests had been missed by the electronic search or to locate additional relevant articles.

The research studies were identified by the following criteria:
 Inclusion criteria:
 The population sample consisted of children without disabilities, aged ≤18 years;
 The variables that were studied had to be compatible with routine pediatric physiotherapy
practice;
 The reports’ findings consisted of age related normative values obtained by the means of
measurement tools that are clinically applicable;
 The research study had to present good internal and external validity.
 Exclusion criteria:
 The population sample consisted exclusively of adult subjects or children with disabilities;
 The testing procedures called for sophisticated equipment.
xiv Normative References Values for Musculoskeletal Conditions and Functional Motor Abilities in the Pediatric Population

PROCEDURES FOR THE SELECTION OF THE STUDIES

The first selection was undertaken by the pediatric physical therapist.

The selected studies were then analyzed by a second reviewer qualified in research methodologies,
who accepted or rejected them based on the following criteria:
 Good internal validity (Selection bias and information bias);
 External validity (On which population can we generalize results).

Search Results

The pediatric literature search yielded 1012 reports.

250 articles were retained for analyses by the pediatric physical therapist based on the inclusion and
exclusion criteria. Review articles were also excluded.

38 articles met the inclusion criteria established for this review, providing pediatric normative
reference values obtained by methods that are easily applicable in a clinical setting.

The selected data from these 38 reports was divided into 54 outcome measures. Table 1
summarizes the findings.

TABLE 1. SUMMARY OF THE FINDINGS FROM THE REVIEW OF THE PEDIATRIC LITERATURE
Number of Number of
Topics Analyzed Outcome Comments
Articles Measures
Most assessments were conducted in gait analysis
Gait 39 7 laboratories. There exists a paucity of research in children’s
mobility in a natural environment.
There is a paucity of research in these domains and sample
Muscle
size is small in most of the selected studies. Only one study
strength and
48 9 was selected for the assessment of trunk muscle strength. No
physical
relevant work was selected for physical fitness. A school
fitness
fitness battery test is presented.
Range of
38 12 Pediatric reports are very limited in number and fewer studies
motion
were found for the upper extremities. There is a lack of
Specific
75 23 current research in the range of motion in healthy children.
tests
Foot assessments are often reported as topics of some
The foot 50 3
debate in the literature.
Many reports were excluded based on the fact that they were
Total 250 54
not clinically applicable.

LIMITATIONS OF THE REVIEW

The review aimed to identify norm-referenced tests with children without disabilities. The studies that
consisted exclusively of impaired children were excluded. These studies may have presented
additional relevant works or other testing methods.

Certain norm-referenced tests that were selected are from descriptive normative studies and do not
present all the psychometric properties of tests and measures.

The selected methods have not all been tested by the authors in their clinical practice. Some of the
methods might not be applicable due to the presence of articular difformities or other medical
conditions.
 Normative References Values for Musculoskeletal Conditions and Functional Motor Abilities in the Pediatric Population xv

The list of the assessment tools and measures is not exhaustive. It represents various testing
methods selected by the physical therapist based on their ease of application in routine clinical
practice and the variable being measured.

The reference manual

TARGET PROFESSIONALS

This manual was first intended for pediatric physical therapists. It will also be of interest to
pediatricians, orthopedists, collegiate and university teachers, students and other professionals
interested in the assessment of the pediatric population.

CONTENTS

A basic understanding of anatomy and of the physiologic musculoskeletal changes is necessary to
address the contents of this manual. It should be looked upon as a reference guide when assessing
children in a clinical setting.

The various standardized assessment tools and the normative reference values originate from the
selected research studies. These assessments, as most methods, must be applied in regards to the
child’s clinical history, symptoms, and functional limits.

TERMINOLOGY

As a general rule, the term ‘’children’’ is used to cover the age range from “birth to 18 years”.
However, if the terms infants, newborns, adolescents, etc., were specifically used in the research
studies, the same terms were kept to avoid confusion when presenting the data.

The male gender is used to define the population in general. Specificity for the female gender is used
when the authors reported differences between sexes.

Description of the testing procedures:
 Standardization of the testing procedures and the application of the authors’ methods are
essential for obtaining accurate results. The majority of the descriptions are the ones used in the
studies and therefore there can be a difference in the description of the method for a similar test.
No attempt has been made to bring into conformity this information.
 Metric and English measures were used depending on the authors’ choice, but both are
presented. Terms such as internal and medial rotations, external and lateral rotations were also
used according to the studies.

PRESENTATION OF THE DATA

Maximum effort has been made to present the data in a brief and complete way, and to render it user-friendly.
A brief summary of the literature review is presented with each topic followed by the selected assessment
tools. This information, with a few exceptions, is divided into five parts:

1) Age range, clinical use and measurements

2) Testing procedures
 Required equipment, testing positions and measurements are described.
 Photos or figures are presented with certain testing procedures.
 Additional information is presented for certain studies when the description for the method was
incomplete.
3) Normative reference values
 In order to respect authors' copyrights, the normative data is presented in their original tables or
figures. Thus additional data that is not necessarily pertinent to the undergoing assessment may
be present.
xvi Normative References Values for Musculoskeletal Conditions and Functional Motor Abilities in the Pediatric Population

 However, for certain studies, we were unable to present the results due to the high cost of
purchase. For these studies, the clinician will have to order the article in order to obtain the
normative data. When possible, a summary of the data is presented but does not in any way
replace the specific normative data from these studies.
 Clinical examples, for certain clinical conditions, are added to facilitate the interpretation of the
data.
4) Clinical practice guidelines
 Medical guidelines from the pediatric orthopedist are presented in the foot section and for a few
clinical conditions in the specific tests section.
 Clinical guidelines from each report are presented in a study summary or with the normative
reference values.
5) Study summary
 The summary of the research method, data analysis and the authors’ conclusions are the main
elements described in this section. This summary is presented after each measurement tool.
 The study’s summary will allow the clinician to take into account the strength and the limits of the
study, and potential errors when interpreting results. A comment section was also added for
additional information on our part.
6) Updated references are presented at the end of each section

INTERPRETATION OF THE RESULTS

Norm-reference tests present mean values and standard deviation (SD) obtained in a healthy
population. “…An important attribute of the SD as a measure of spread is that if the mean and SD of
a normal distribution are known, it is possible to compute the percentile rank associated with any
9
given score...”
In a normal distribution, about 68% of the scores are within one SD of the mean and about 95% of the
9
scores are within two SD of the mean (Fig.1). In other words, statistically, the term “normal”
represents a condition that is within two SD of the mean which encompasses 95% of the healthy
4, 5
individuals. However, most of the selected studies have presented the data within one SD of the
mean value. Thus, if need be, the clinician will have to calculate the mean values within the 2 SD.
This is achieved by multiplying by two the one SD value.

A: In a normal distribution of data, about 68% of the data values will fall within one standard
deviation (±σ) of the mean value ( ).(© IRDPQ-2010).

B: In a normal distribution of data, about 95% of the data values will fall within two standard
deviations (±2σ) of the mean value ( ).(© IRDPQ-2010).
Figure 1. Interpretation of mean values and standard deviation. A: Data within one standard
deviation (±σ) of the mean value. B: Data within two standard deviations (±2σ) of the mean
value.
 Normative References Values for Musculoskeletal Conditions and Functional Motor Abilities in the Pediatric Population xvii

How to use the results?

7) The results of the impaired child are compared to the normative reference values in order to
document if restrictions exist and to determine the severity of the impairment. However, mean values
and standard deviations are useful clinically but should not be analyzed in an absolute manner and
interpreted as the only criteria for clinical decisions and determining the child’s status. Evidence-
based medecine is “…the conscientious, explicit and judicious use of current best evidence in making
1,6
decisions about individual patients…” . Identifying patient expectations and goals are important
8
parts of best practice. In summary, final clinical diagnosis, therapeutic decisions and interventions
depend on research evidence, clinical expertise, the child’s clinical - medical history, and the family’ s
preferences.
8) Children with disabilities usually do not present normal developmental patterns as compared to
children without disabilities. Abnormal muscle tone, joint limitations, muscle weakness or various
medical conditions are known as factors that can interfere in the child’s development. Close follow-up
is thus suggested with children presenting disabilities and who have a condition that is rated in the
two SD limits, showing a potential risk to evolve towards functional and musculo skeletal problems.

Conclusion

This document is a compilation of different standardized tests for various musculoskeletal problems and
functional motor abilities often seen in pediatric physical therapy. All the testing procedures are convenient for
use by clinicians and acceptable for the pediatric patient. Clinical practice guidelines are presented with each
research study. The content is, to the best of our knowledge, among the most current research findings that
can be used in a clinical practice setting at the moment this review was undertaken.

Since standardization issues are critical for comparison of test results, the use of standardized tests presented
in this document will help to achieve more objective measurements and results. These tests will also help to
diminish errors when the child is assessed by different raters and in follow-ups.

The use of normative data will contribute to a better knowledge of the pediatric musculoskeletal
developmental specificities and will be useful as a clinical reference in professional practice. It will also help to
identify the restrictions and limitations regarding the child’s age and guide program planning.

The literature review revealed a paucity of current studies presenting normative reference values with reliable
outcome measures in the healthy pediatric population. There is variation in the quality in the studies, certain
having a small sample size and lacking psychometric criteria. However the data can be used as baseline
values. The more rigorous studies were undertaken in the last decade.

This work, we hope, is a step forward in answering the need and demand for outcome measures,
documentation and objective testing in the field of pediatric rehabilitation. It will help to address the challenge
in identifying the normal dynamic process in the child’s development and hopefully stimulate future research
projects to study other variables in the unimpaired and impaired pediatric population.

Anne Parrot, PT.

Michel Tousignant, PhD, PT.
Yvan St-Cyr, MD, Orthopaedic Surgeon.
xviii Normative References Values for Musculoskeletal Conditions and Functional Motor Abilities in the Pediatric Population

References

RESEARCH ARTICLES
1. Haynes, R. B., Sacket, D. L., Gray, J. M., Cook, D. J. & Guyatt, G. H. (1996). Transferring evidence
from research into practice: 1. The role of clinical care research evidence in clinical decisions. ACP
Journal Club, 125, (3), A14-A16.

2. Knutson, L. M, Schimmel, P. A. & Ruff, A. (1999). Standard Task Measurement for Mobility: Thirty-
Second Walk Test. Pediatric Physical Therapy, 11, 183-190.

3. Majnemer, A. & Limperopoulos, C. (2002). Importance of outcome determination in pediatric

rehabilitation. Developmental Medicine and Child Neurology, 44, 773–777. doi: 10.1111/j.1469-
8749.2002.tb00285.x

4. Sobel, E., Levitz S. J., Caselli, M. A., Tran, M., Lepore, F., Lilja, …M. & Wain, E. (1999). Reevaluation
of the relaxed calcaneal stance position. Reliability and normal values in children and adults. Journal
of the American Podiatric Medical Association, 89, 258-264.

5. Staheli, L. T., Corbett, M., Wyss, C. & King, H. (1985). Lower-extremity rotational problems in
children. Normal values to guide management. Journal of Bone & Joint Surgery: American volume. 6,
39-47.

6. Sackett, D. L., Rosenberg, W., M, Gray, J. A., Haynes, R. B. & Richardson, W. S. (2007). Evidence
based medicine: what it is and what it isn't. British Medical Journal. 312, 71-72.

WEB SITES
7. Brunham, S., Forwell, S.J. & Miller, D. (2004). Rehabilitation Outcomes for Clinical Practice &
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th
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8. HyperStat Online Contents. Standard deviation and variance. Retrieved from

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http://davidmlane.com/hyperstat/A16252.html Accessed on March 8 , 2010

9. What is evidence-based and best practice in physiotherapy?. Canadian Physiotherapy Association.

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