Physical examination of the upper extremity in the pediatric client includes the same components pertinent to the adult population. However, methods of assessment must be tailored to the developmental level of the patient. Infants and young children have limited attention spans, less ability to follow directions, and are often uncooperative with unfamiliar adults. Patience, age-appropriate language, and a ready supply of toys and props will lead to a more successful evaluation. Evaluations performed on the floor, at a child-sized table, or from a trusted caregiver’s lap can build rapport and improve participation. When working with children, including the family is imperative. Caregivers often provide history; explain what the child can do and actually does on a daily basis; and are important to supporting carryover at home. Videos or photographs of participation in daily activities in the child’s environment provide valuable information that may be difficult to elicit in the clinic.
Children will often try to “get the right answer” on the examination, especially when they know what the clinician is assessing. For example, a 6-year-old child with a history of pollicization may demonstrate consistent incorporation of her thumb when handed various objects by the therapist. However, in the waiting room, she demonstrates interdigital scissoring pinch for small objects. Her mother reports that she uses her thumb for cups and balls, but prefers scissor pinch for small items. A combination of formal assessment, observation, and family interview provides a more accurate picture of the child’s true function.
Range of Motion
A precise assessment of range of motion is essential to identify limitations and tracking progress with intervention. Active range of motion (AROM) and passive range of motion (PROM) measurements can be challenging with infants and young children due to pain, fearfulness, limited attention span, and small hand size. Children may be afraid when they see an unfamiliar tool. When possible, handing the goniometer to the child to “measure” a parent or clinician often helps to reduce fear. At times, the goniometer will not be tolerated and the therapist is required to use his or her “ocular goniometer” to assess motion. Beginning with AROM measurements can help to build trust before handling, however if the child has difficulty following instructions starting with PROM can model the desired movement. For children having difficulty tolerating the assessment, prioritizing the most important measures and completing others later is a necessary strategy.
With young children, it is often challenging to take accurate goniometric measurements of active motion. Small hand size can make measuring active and passive digital movement difficult. Alternative play-based measurements may be necessary. For example, composite flexion may be quantified by measuring the diameter of the smallest marker the child can grasp. Alternative measures should be objective and repeatable to track progress over time. Limited attention spans or ability to follow directions can lead to difficulty maintaining maximum effort at end range. Having the goniometer in position to measure quickly and engaging a parent to elicit the desired motion can assist the process. Games, such as Simon Says, can also help engage and build rapport with younger clients. Patients who have sustained a traumatic injury may have their effort limited by pain or fear of pain. Beginning with moving unaffected adjacent joints may reduce guarding postures. A functional task may produce more movement than instructions to move in a particular plane.
The concept of scaffolding should be utilized to elicit challenging motions. This refers to beginning in the range where the child experiences success and gradually building the challenge, rather than starting in a range that is out of reach. For example, a toddler with a brachial plexus injury with limited shoulder abduction may not even attempt to reach for a sticker held overhead. By presenting the sticker at chest height, the child experiences success. From here, the stimulus can be gradually raised higher until the AROM limit is achieved ( Fig. 3.1 ).
PROM assessment is often difficult for clients who have pain or have had negative experiences with stretching over time. Other children may have limited tolerance for handling or being still for the assessment. Distractions such as music or videos may help the child relax for the exam. Patience and time may be necessary to slowly move the affected joint and avoid eliciting muscle guarding and discomfort. Any stretches that are anticipated to cause discomfort should be saved for the end of the examination. One example is passive shoulder external rotation for children with brachial plexus palsy and suspected internal rotation contracture. Initiating the evaluation with this stretch in an infant or toddler may cause them to shut down, negating any additional assessment of arm function.
Children with range of motion deficits, especially congenital conditions, will develop adaptations to function within their abilities. Careful observation of these compensatory strategies will highlight areas that require further assessment. Excessive wrist flexion can be observed during midline function in children with brachial plexus birth palsy who demonstrate limitations in internal rotation limitation. Wrist flexion is also used as a compensatory strategy for self-feeding in a child lacking elbow flexion after an elbow injury. Patients with arthrogryposis multiplex congenita (AMC) often develop several compensatory patterns to overcome limitations ( Fig. 3.2 ). For clients with chronic conditions that create limited potential for improvement in range of motion, these patterns are encouraged. However, in conditions where further recovery is expected, these movement patterns are discouraged to eliminate ongoing and unnecessary compensatory movement patterns.
Strength
Strength assessment in pediatric clients can be challenging for many of the reasons noted in the previous section. Manual muscle testing (MMT) can be utilized in older children and adolescents. Beginning with larger joints, clear instructions and comparison to the unaffected side, when possible, will allow the clinician to assess if a child is able to participate in the exam. For patients with limited attention spans, focus on the key muscles to test to elicit maximum effort. Making strength testing a game can help to increase participation. In addition to MMT, dynamometry for grip and pinch strength has established norms for children as young as 6 years old.
Upper extremity strength in infants and toddlers should be assessed through observation of function. This can be objectively measured by presenting toys with different sizes and monitoring how long the child can maintain grasp or lift the toy. Movement is compared in antigravity and gravity-eliminated planes. As the child moves through developmental positions, such as quadruped or pulling to stand, assess for symmetrical weight bearing and inclusion of the affected side. The Active Movement Scale was developed for measuring strength in infants with obstetrical brachial plexus palsy. Although reliability studies focus on this population, this scale can be used clinically for infants with other diagnoses to obtain an objective comparison of strength changes.
Compensatory movements may conceal weaknesses and require careful scrutiny. A teenage patient with absent triceps from a C6 spinal cord injury may appear to have 2/5 MMT strength via shoulder external rotation and supination. However, palpation, blocking external rotation, and any attempt at antigravity movement will reveal that the triceps is not functioning. Extensor digitorum communis and the long finger flexors (flexor digitorum profundus and superficialis) can act upon the wrist in the presence of weak wrist extension or flexion, respectively ( Fig. 3.3 ). Proximal momentum can be utilized to augment shoulder or elbow flexion. In the absence of active elbow flexors, children may utilize the Steindler effect. This occurs when forearm protonation and wrist and finger flexion are paired with momentum to initiate elbow flexion. The child is able to hold the elbow in flexion by contracting the flexor/pronator muscles that originate proximal to the elbow. When in doubt, having the child reproduce the movement slowly can often elucidate what is powering the motion.
