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Normal Values of Functional Reach and Lateral Reach Tests in Children With Knee Hypermobility Abhijeet A. Deshmukh, BPTh, MPT VSPM’s College of Physiotherapy, Lata Mangeshkar Hospital and Medical College, Nagpur, Maharashtra, India.
Purpose: To measure values for functional reach (FR) and lateral reach (LR) in school children with knee joint hypermobility (KJH), and to examine the correlation of anthropometric measures and KJH with FR and LR values. Methods: A total of 140 children aged 6 to 12 years with typical development (TD) and bilateral KJH of greater than 10◦ hyperextension participated. Three successive trials of FR and LR tests in standing position with feet shoulder width apart were performed, and the mean of the 3 trials was calculated. Analysis of variance and Bonferroni tests were used to analyze correlation and association of FR and LR values with KJH angle and anthropometric data, respectively, with a 95% confidence interval. Results: In school-aged children with TD, height and KJH contributed significantly to the FR values in both genders, whereas height contributed for LR values among girls alone. Conclusions: Height and KJH affect children’s scores on the FR and LR tests of balance. (Pediatr Phys Ther 2014;26:230–236) Key words: body measures, children, female, India, joint hypermobility, knee joint, male, postural balance INTRODUCTION Balance is the ability to maintain the body’s center of gravity within the limits of the base of support with minimal sway or maximal steadiness,1-3 and the process by which postural stability is maintained or controlled within the limits of the base of support.4,5 In children, balance plays an important role in activities like playing, walking, reaching, and running. The maintenance of balance involves coordination of visual, vestibular, and somatosensory information. In early childhood, balance depends on the visual-vestibular system and slowly changes to depend on the somatosensory and 0898-5669\110/2602-0230 Pediatric Physical Therapy C 2014 Wolters Kluwer Health | Lippincott Williams & Copyright Wilkins and Section on Pediatrics of the American Physical Therapy Association
Correspondence: Abhijeet A. Deshmukh, BPTh, MPT, VSPM’S College of Physiotherapy, Lata Mangeshkar Hospital and Medical College, Digdoh Hills, Hingna Road, Nagpur 440019, Maharashtra, India ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.pedpt.com). The author declares no conflicts of interest. DOI: 10.1097/PEP.0000000000000031
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vestibular systems.4,5 Adult-like balance responses develop after the age of 6 years.4,6 Balance abilities can be divided into static and dynamic components. Static balance is defined as “the ability to maintain a posture such as balancing in standing or sitting,”5 and dynamic balance is defined as “the ability to maintain postural control during movements such as reaching for an object or walking on various surfaces.”7 Overall balance capability and postural stability increases and matures by 6 to 10 years of age.3,6 As balance improves in children, it allows them to perform activities of daily living independently.7 The somatosensory system is composed of the receptors and processing centers to integrate the sensory modalities such as touch, temperature, proprioception (body position, movement sensation and amount of forc generation), and nociception (pain).8 Proprioception, the acquisition of stimuli from conscious and unconscious processes in the sensorimotor system,9 is the process which underlies the ability to vary muscle contraction in immediate response to incoming information regarding external forces, by using all proprioceptive receptors surrounding joints and in the muscles to keep track of joint positions in the body.10 Proprioceptive sensory feedback is used by the central nervous system for conscious and unconscious appreciation of the position, movement, and force generated by the body and limbs. In patients with joint hypermobility, Pediatric Physical Therapy
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it has been suggested that proprioceptive acuity is altered.9,12,13 Joint hypermobility, that is, increased joint range of motion, is seen either as a localized condition, for example, in a single joint, or a more generalized one. When seen in parallel with musculoskeletal problems, the total condition is recognized as pathological and is called hypermobility syndrome.14,15 Instead of classifying hypermobility using range of motion in degrees, several authors used the presence of a certain extreme range of motion as a criterion for hypermobility. Previously used criteria for joint hypermobility have been revised, and currently the Beighton tests have gained international acceptance and seem to be the most widely used test today for diagnosing general joint hypermobility.14,16,17 Various tests are available to assess balance in children. Of the tests available, the Functional Reach (FR) and Lateral Reach (LR) Tests are commonly preferred for use in routine clinical and community settings. They are easy to understand, quickly performed, easy to score, and cost-effective, and no special equipment is required.4,9 The FR Test measures dynamic balance in a functional context of reaching forward.4,7,10 Functional reach, as developed and defined by Duncan et al,11 is the maximal distance one can reach forward beyond arm’s length while maintaining a fixed standing position. In children, the FR Test has been proposed as a discriminative test and as a diagnostic test to document feed-forward mechanisms of postural control,7,8 one of the components of the pediatric balance scale in school-aged children.4,7,8,10 Recent studies have been performed on the FR Test in India by Deshmukh et al4 and in western countries by Donahoe et al7 in school-aged children considered to be healthy and developing typically. The interrater, intrarater, and testretest reliability of the FR Test has been reported to be 0.98, 0.83, and 0.75, respectively.4,5,8 The LR Test measures postural stability in the mediallateral direction by assessing the maximum distance an individual can reach laterally beyond arm’s length at shoulder height, while maintaining a fixed base of support in the standing position.2,4,9,14 According to a previous study, lateral falls occur more frequently among the elderly population,18 leading to many complications; hence by measuring LR distance, medial-lateral stability can be assessed, which helps identify risk of falls, but this finding is not yet proved in children. The data for normal values of the FR Test and LR Test according to the studies carried out in India and Western countries are available. According to an Indian study, the normal value of the FR Test range from 22.7 (±3) to 37 (±4.4) cm and normal values for the LR Test range from 16.3 (±2.3) to 22.5 (±3.3) cm in children ranging in age from 6 to 12 years.4 Height contributes significantly among all the anthropometric measures, to both FR and LR Test values.4,7,18,19 The FR Test values proposed by Donahoe et al7 ranged from 21.17 to 32.79 cm for a similar age group in the United States.
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Despite recent studies of the FR and LR Tests in children aged 6 to 12 years, studies of FR and LR in those with joint hypermobility are lacking. Joint hypermobility is commonly seen in young children who are healthy, and is more common among girls than boys.12,14 The knee commonly displays hypermobility.13 Therefore, the aim of the study was to measure the FR and LR distance in school-aged children with knee joint hypermobility (KJH) of 10◦ hyperextension or more,20 and to examine their association with age, gender, and anthropometric factors. METHODS A cross-sectional study was performed using a multistage stratified sampling method. A total of 850 children were screened from 2 city schools. All the children from each class were screened for KJH, and of them, 10 subjects were selected from each class, using a random number table method. Consent and assent forms were obtained from all screened subjects. This was possible because of the cooperation of class teachers and school management, who generously had sent a recommendation letter for the study to all parents, and hence got approval from all parents, and therefore no subject replacement was needed in the study. A sample of 140 subjects (70 boys and 70 girls) within the age group of 6 to 12 years was selected from 2 schools. The subjects were divided into 7 subgroups depending on age, that is, 6, 7, 8, 9, 10, 11, and 12 years. Each subgroup had 20 subjects (10 boys and 10 girls). Children of both genders who had KJH were included. Children of both genders with typical development (TD) and between the ages of 6 and 12 years with the ability to stand for at least 2 minutes without support were included in the study. Children with any history of middleear infection within the past 6 months, any visual difficulties, any history of recent fractures of the lower limbs, and if height or weight fell below the 10th or above the 90th percentile for gender and age were excluded.4 PROCEDURE Approval from the scientific committee was obtained before the commencement of the study. Permission was taken from the Block Education Officer, and the list of schools was collected. Of 244 higher primary schools in the city, 2 schools were selected by simple random sampling using the random number table method. Permission was obtained from the school authorities to carry out the study. The classes where the target population was present were selected by lottery method. The subjects were selected on the basis of inclusion and exclusion criteria. The information sheet and the consent form were sent for the approval of the parents, and the assent form was completed by the subject. The subject was included in the study once the approval was received.
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The purpose of the study and the test procedure for FR and LR (Appendix available online as Supplemental Digital Content 1, http://links.lww.com/PPT/A60) was explained to teachers and the children. The test procedure was demonstrated to avoid compensatory activities. The demographic data of the subjects, that is, age and gender, were obtained from the school records. A weighing scale and a measuring stick were used to measure anthropometric data, including weight in kilograms and height in centimeters, respectively. The children were screened for KJH, which was defined as knee hyperextension of more than 10◦ for children20 and was measured bilaterally with the help of universal half-circle goniometer (Appendix available online as Supplemental Digital Content 1, http://links.lww.com/PPT/A60). The distance between the 2 acromion processes of the shoulders was used to define the base of support in the standing position (distance between 2 parallel feet).4 Each subject was given 3 successive trials of FR and LR separately. The mean value of these 3 trials was calculated and recorded.4 A 1-minute rest was given between the FR and LR Tests. See Figures 1 and 2. DATA ANALYSIS The Statistical Package for Social Science version 16.0 was used for data analyses. Descriptive statistics were obtained for normal values of the FR and LR Tests for all age groups along with the 95% confidence interval. Anal-
Fig. 2. Position for Lateral Reach Test.
ysis of variance was used to examine the relationship of age, gender, KJH, and base of support with the FR and LR Tests. Pair-wise comparisons for all the parameters were done using the Bonferroni test. RESULTS The values of FR for children with bilateral KJH ranged from 24.37 ± 1.97 to 28.77 ± 3.22 cm, and LR mean values ranged from 17.30 ± 0.97 to 19.20 ± 1.79 cm in the age group of 6 to 12 years. The demographic data of height, weight, body mass index, and base of support for boys and girls aged 6 to 12 years are given in Table 1. The means and SDs of height, FR distance, LR distance, and KJH angle among boys and girls from 6 to 12 years are shown in Table 2. Figures 3 and 4 show the mean FR and LR distance among boys and girls 6 to 12 years old. The Correlation of Mean FR and LR Distance With Mean KJH in Boys
Fig. 1. Position for Functional Reach Test. 232
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Table 3 shows the correlation of mean FR and LR distance with mean KJH angle in boys. The correlation coefficients for the FR and LR were 0.86 and −0.19, respectively. The FR distance among the boys showed a significant negative correlation, whereas LR distance showed no correlation with KJH angle. This means that as KJH increases, FR values decrease among boys but KJH is not related to LR values. Pediatric Physical Therapy
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TABLE 1 Demographic Data Age, y 6 7 8 9 10 11 12
Gender
Subjects, n
Height, Mean ± SD
Weight, Mean ± SD
Body Mass Index
Base of Support
Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls
10 10 10 10 10 10 10 10 10 10 10 10 10 10
106.70 ± 3.23 107.20 ± 2.10 120.90 ± 5.76 122.40 ± 4.03 120.30 ± 5.10 120.40 ± 2.88 128.10 ± 4.58 126.60 ± 3.84 134.70 ± 5.44 134.20 ± 5.67 141.80 ± 6.46 135.20 ± 7.54 139.80 ± 4.18 135.30 ± 6.27
16.50 ± 1.58 14.00 ± 1.05 18.80 ± 3.39 16.80 ± 1.62 18.60 ± 3.24 18.00 ± 1.33 26.90 ± 3.11 25.40 ± 3.47 27.10 ± 2.64 25.60 ± 2.01 30.90 ± 5.04 29.70 ± 4.11 38.10 ± 5.32 36.80 ± 3.05
14.69 12.28 13.05 11.35 12.91 12.5 16.50 16.07 15.13 14.30 15.60 16.31 19.74 20.21
26.00 25.90 27.30 27.40 27.50 27.20 28.20 28.80 31.30 31.30 28.80 27.40 28.70 28.70
TABLE 2 Height, Knee Joint Hypermobility Angle, FR Distance, and LR Distance Among Boys and Girls Aged 6 to 12 Years
Age, y 6 7 8 9 10 11 12
Gender
Subjects, n
Height, Mean ± SD, cm
Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls
10 10 10 10 10 10 10 10 10 10 10 10 10 10
106.70 ± 3.23 107.20 ± 2.10 120.90 ± 5.76 122.40 ± 4.03 120.30 ± 5.10 120.40 ± 2.88 128.10 ± 4.58 126.60 ± 3.84 134.70 ± 5.44 134.20 ± 5.67 141.80 ± 6.46 135.20 ± 7.54 139.80 ± 4.18 135.30 ± 6.27
Knee Joint Hypermobility Angle, Mean ± SD, ◦
FR Distance, Mean ± SD, cm
LR Distance, Mean ± SD, cm
14.70 ± 2.00 16.00 ± 2.16 14.30 ± 3.16 15.80 ± 2.85 14.10 ± 2.02 15.10 ± 3.11 14.00 ± 2.56 15.00 ± 3.00 13.90 ± 2.26 14.90 ± 2.62 13.80 ± 2.55 14.70 ± 2.58 13.70 ± 2.79 14.50 ± 2.59
24.37 ± 1.97 25.10 ± 2.16 25.47 ± 3.84 25.73 ± 2.94 26.13 ± 3.21 26.90 ± 3.40 27.27 ± 2.78 27.20 ± 3.49 28.03 ± 2.23 27.50 ± 2.32 28.07 ± 2.65 27.37 ± 2.75 28.77 ± 3.22 27.67 ± 2.65
17.30 ± 0.97 17.53 ± 1.32 17.77 ± 2.00 18.43 ± 2.56 17.85 ± 1.01 18.52 ± 1.96 17.90 ± 1.68 18.53 ± 1.85 18.32 ± 1.76 18.67 ± 2.31 18.60 ± 2.14 18.73 ± 1.53 19.20 ± 1.79 18.95 ± 1.87
Abbreviations: FR, functional reach; LR, lateral reach.
Fig. 3. Gender-wise comparison of mean values of functional reach distance with age.
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Fig. 4. Gender-wise comparison of mean values of lateral reach distance with age.
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TABLE 3 Correlation of FR Distance and LR Distance With Height and Knee Joint Hypermobility Angle Among the Boys and Girls Aged 6 to 12 Years FR Distance (6 to 12 y) Anthropometric Measures
LR Distance (6 to 12 y)
Analytical Values
Boys
Girls
Boys
Girls
r t P r t P
0.8973 4.43 .0068a −0.8680 3.19 .0113 b
0.899 4.60 .006a −0.9599 7.66 .0006a
0.2611 0.60 .57 b −0.1903 0.4334 .68
0.8595 3.75 .013 b −0.6534 1.93 .1115
Height
Knee joint hypermobility angle
Abbreviations: FR, functional reach; LR, lateral reach. a P ≤ .001. b P ≤ .05.
The Correlation of Mean FR and LR Distance With Mean KJH in Girls Table 3 shows the correlation of mean FR and LR values with the mean KJH angle in girls. The correlation coefficients for FR and LR were −0.95 and −0.65, respectively. The FR distance among the girls showed a significant negative correlation, while LR distance showed no significant correlation with KJH angle. This means that as KJH increases, FR values decrease among girls but does not show any relationship to LR values.
ues in both boys and girls, whereas the mean LR values showed a significant correlation only in girls. These results are in accord with the previous study.4 DISCUSSION The anthropometric measurements of the subjects included in the present study were in agreement with the Indian data4,21 for the same age groups. As shown in Table 4, the normal mean values for the FR ranged from 24.37 ± 1.97 to 28.77 ± 3.22 cm and LR
The Correlation of Mean FR and LR With Mean Height in Boys Table 3 shows the correlation of mean FR and LR with mean height in boys. The correlation coefficients for FR and LR were 0.89 and 0.26, respectively. The FR distance among the boys showed a significant positive correlation, whereas LR showed no significant correlation with height. This means that as height increases, FR values increase among boys but are not associated with LR values. The Correlation of Mean FR and LR With Mean Height in Girls Table 3 shows the correlation of mean FR mean LR with mean height in girls. The correlation coefficients were 0.89 and 0.85 for FR and LR, respectively. The FR distance among the girls showed a significant positive correlation with height, whereas LR distance showed a significant correlation with height. This means that as height increases, FR values increase among girls as do LR values.
Fig. 5. Gender-wise comparison of mean value of KJH angle with age.
Mean KJH Among Boys and Girls Figure 5 shows mean KJH for boys and girls 6 to 12 years of age, which demonstrates that as age increases, KJH decreases among girls more than boys. The results of the present study suggest that the lowerlimit values of FR and LR are similar, but higher limits showed lower values in subjects aged 6 to 12 years with hypermobility of the knee joint when compared with the data established by Deshmukh et al for children with TD.4 Height showed a significant correlation with mean FR val234
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TABLE 4 FRT and LRT Results in 3 Studies Study Present study Deshmukh et al4 Donahoe et al7
FRT, cm
LRT, cm
24.37 ± 1.97 to 28.77 ± 3.22 22.7 ± 3 to 37 ± 4.4 21.17 to 32.79
17.30 ± 0.97 to 19.20 ± 1.79 16.3 ± 2.3 to 22.5 ± 3.3 ...
Abbreviations: FRT, Functional Reach Test; LRT, Lateral Reach Test.
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mean values ranged from 17.30 ± 0.97 to 19.20 ± 1.79 cm in children from 6 to 12 years with KJH. The mean values proposed by Deshmukh et al4 for FR for a similar age group without hypermobility ranged from 22.7 ± 3.0 to 37 ± 4.4 cm and for LR ranged from 16.3 ± 2.3 to 22.5 ± 3.3 cm. The FR values proposed by Donahoe et al7 ranged from 21.17 to 32.79 cm for a similar age group in the United States. The values for FR and LR distance in this study among children 6 to 12 years with KJH are within the normal range, but they show a relatively reduced ability to achieve greater range when compared with children in the previous study.4 The results of this study reveal that FR and LR distances among boys and girls from 6 to 12 years are affected by factors such as height and KJH angle. Height is an important factor affecting FR and LR distance in children.4,7,18,19 The height of children in this study is less when compared with the previous study; hence, the values of FR and LR distance are relatively less in this study. In previous studies,9,12,13,22 it was found that knee joint proprioception becomes impaired in children with hypermobility syndrome and the children show weaker knee extensor and flexor muscles than healthy controls. In this study, children with knee joint hypermobility were included, which may have led to reduced joint proprioception and balance. Therefore, this could be a reason for relatively lower values of FR and LR distance. The effects of age, gender, height, base of support, and knee hyperextension angle were determined by using stepwise regression. Results showed that a direct correlation of height with FR and LR distance exists, which shows that as height increases, in both genders, a significant increase in FR distance is found, whereas LR distance increases significantly with height among girls alone. In this study, the knee hyperextension angle showed an inverse relationship with FR distance. As the hyperextension angle decreases, the FR distance increases in both boys and girls from age 6 to 12 years. Whereas, LR distance values showed no significant correlation with KJH in both boys and girls. This finding can be explained on the basis of the hypothesis that when anterior-posterior hypermobility present is in joints, FR will be more affected than LR. As in the present study, all children with knee hyperextension were included; hence one could expect this to affect forward reach alone rather than lateral reach. In this study, no children with defects in medial-lateral joint stability were included. Hence, it was found that the FR distance values were relatively less than in the previous study,4,7 and LR distance values did not show any significant relationship with the knee hyperextension angle in either gender. In this study, the children with generalized hypermobility as well as KJH alone were included. It has been shown previously that there is lack of joint control and proprioception in hypermobile joints, thus affecting balance.9,12,13,22 Thus, from the present study, it can be concluded that KJH among girls and height among both boys and girls are Pediatric Physical Therapy
the main contributing factors leading to variations in FR, and height among girls alone affects LR.
IMPLICATIONS FOR RESEARCH AND CLINICAL PRACTICE The result found in this study can be used as comparative data for assessment of balance impairments in children with KJH along with consideration of height. In this study, lower limb strength and joint position sense examinations were not completed, which could influence FR and LR values. Hence, in future research muscle strength of the lower extremity should be evaluated along with knee joint position sense. In this study, children with both generalized hypermobility and KJH alone were considered in one group. A comparative study between conditions of generalized joint hypermobility and localized KJH should be considered to allow greater accuracy in the evaluation of results. And, proprioception should be evaluated in these separate groups.
CONCLUSION In school-aged children, height and KJH contribute significantly to the FR values in both genders, whereas height contributes to LR values among girls alone.
REFERENCES 1. Emery C, Cassidy D, Klassen T, Rosychuk R, Rowe B. Development of a clinical static and dynamic standing balance measurement tool appropriate for use in adolescents. Phys Ther. 2005;85(6):502-514. 2. Horak FB. Clinical measurement of postural control in adults. Phys Ther. 1987;67(12):1881-1885. 3. Shumway-Cook A, Woollacott MH. Motor Control: Theory and Practical Applications. 4th ed. Baltimore, MD: Williams & Wilkins; 2010. 4. Deshmukh A, Sailaksmi G, Tedla J. Normal values of Functional Reach Test and Lateral Reach Test in Indian school children. Pediatr Phys Ther. 2011;23:1-8. 5. Westcott SL, Lowes LP, Richardson PK. Evaluation of postural stability in children: current theories and assessment tools. Phys Ther. 1997;77:629-645. 6. An M, Yi CW, Jeon H, Park S. Age-related changes of single-limb standing balance in children with and without deafness. Int J Paediatr Otorhinol. 2009;73:1539-1544. 7. Donahoe B, Turner D, Worrell T. The use of Functional Reach as a measurement of balance in boys and girls without disabilities ages 5 to 15 years. Pediatr Phys Ther. 1994;6:189-193. 8. Norris RA, Wilder E, Norton J. Functional Reach Test in 3 to 5 year old children without disabilities. Pediatr Phys Ther. 2008;20:47-52. 9. Callaghan M, Selfeb J, McHenry A, Oldham J. Effects of patellar taping on knee joint proprioception in patients with patellofemoral pain syndrome. Man Ther. 2008;13(3):192-199. 10. Hatzitaki V, Zisi V, Kollias I, Kioumourtzoglou E. Perceptual-motor contributions to static and dynamic balance control in children. J Mot Behav. 2002;34:161-170. 11. Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: a new clinical measure of balance. J Gerontol. 1990;45(6):M192-M197. 12. Mallik AK, Ferrell WR, McDonald AG, Sturrock RD. Impaired proprioceptive acuity at the proximal interphalengeal joint in patients with the hypermobility syndrome. Br J Rheumatol. 1994;33(7):631-637. Balance and Knee Hypermobility in Children
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13. Hall M, Ferrell R, Sturrock R, Hamblenf D, Baxendale R. The effect of the hypermobility syndrome on knee joint proprioception. Br J Rheumatol. 1995;34(2):121-125. 14. Juul-Kristensen B, Rogind H, Jensen D, Remvig L. Inter-examiner reproducibility of tests and criteria for generalized joint hypermobility and benign joint hypermobility syndrome. Rheumatology. 2007;46:1835-1841. 15. Carter C, Wilkinson J. Persistent joint laxity and congenital dislocation of the hip joint. J Bone Joint Surg. 1964;46:40-45. 16. Corben T, Lewis J, Petty N. Contribution of lumbar spine and hip movement during the palms to floor test in individuals with diagnosed hypermobility syndrome. Physiother Theory Pract. 2008;24(1):1-12. 17. Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Ann Rheum Dis. 1973;32:413.
18. Takahashi T, Ishida K, Yamamoto H, et al. Modification of the Functional Reach Test: analysis of lateral and anterior functional reach in community-dwelling older people. Arch Gerontol Geriatr. 2006;42:167-173. 19. Habib Z, Westcott S. Assessment of anthropometric factors on balance tests in children. Pediatr Phys Ther. 1998;10:101109. 20. Russek LN. Hypermobility syndrome. Phys Ther J. 1999;79(6):591599. 21. Parthasarathy A, Menon PSN, Gupta P, Nair MKC. Growth and development. In:Agarwal KN, ed. IAP Textbook of Pediatrics. 4th ed. New Delhi, India: Jaypee Brothers; 2009:94. 22. Fatoye F, Palmer S. Proprioception and muscle torque deficits in children with hypermobility syndrome. Rheumatology. 2009;48(2):152157.
CLINICAL BOTTOM LINE Commentary on “Normal Values of Functional Reach and Lateral Reach Tests in Children With Knee Joint Hypermobility”
“How could I apply this information?” The author suggests that hypermobility may negatively affect performance on the Functional Reach and Lateral Reach Tests. In this study, schoolchildren from India with increased knee hypermobility reached a shorter distance on the Functional Reach Test. In addition, taller boys and girls reached a longer distance on the Functional Reach Test and taller girls reached further on the Lateral Reach Test. The data suggest that hypermobility has a negative effect on functional balance especially when reaching forward. The clinician may find it helpful, when assessing balance in children, to evaluate knee joint hypermobility. Information gained from using both of these clinical measures together may provide information about underlying mechanisms of postural control as well as balance. This information will assist the clinician in identifying and providing more focused intervention aimed at increasing functional balance when treating children with excessive range of motion at the knee. “What should I be mindful about when applying this information?” The participants in the study are from India and, as the author stated, the functional reach norms from India are different from the norms from the United States. Therefore, the distances reached in this study may not be directly applicable to children outside India. In addition, these measurements were taken on a population developing typically. Other factors, which may affect a child’s balance when performing the Functional Reach Test (such as forefoot pronation, hip alignment [anteversion], and muscle strength), were not considered. As a consequence, clinicians should be cautious when drawing conclusions and designing treatment strategies for children with knee joint hypomobility. Treatment strategies should not be developed without considering additional information such as postural alignment, lower extremity muscle strength, and proprioceptive awareness. Although an analysis of variance was used, the author reported only correlational data and not differences between groups. Because of the design of the study, we cannot say that hypermobility causes the test results, only that the 2 findings are related. Further research on children with hypermobility linked to a developmental diagnosis is needed.
Julia Looper, PT, PhD University of Puget Sound, Tacoma, Washington Penny Coyner, PT, MPT, PCS Northwest Pediatric Therapies, Issaquah, Washington The authors declare no conflicts of interest. DOI: 10.1097/PEP.0000000000000032
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A R T I C L E
Normal Values of Functional Reach and Lateral Reach Tests in Children With Knee Hypermobility Abhijeet A. Deshmukh, BPTh, MPT VSPM’s College of Physiotherapy, Lata Mangeshkar Hospital and Medical College, Nagpur, Maharashtra, India.
Purpose: To measure values for functional reach (FR) and lateral reach (LR) in school children with knee joint hypermobility (KJH), and to examine the correlation of anthropometric measures and KJH with FR and LR values. Methods: A total of 140 children aged 6 to 12 years with typical development (TD) and bilateral KJH of greater than 10◦ hyperextension participated. Three successive trials of FR and LR tests in standing position with feet shoulder width apart were performed, and the mean of the 3 trials was calculated. Analysis of variance and Bonferroni tests were used to analyze correlation and association of FR and LR values with KJH angle and anthropometric data, respectively, with a 95% confidence interval. Results: In school-aged children with TD, height and KJH contributed significantly to the FR values in both genders, whereas height contributed for LR values among girls alone. Conclusions: Height and KJH affect children’s scores on the FR and LR tests of balance. (Pediatr Phys Ther 2014;26:230–236) Key words: body measures, children, female, India, joint hypermobility, knee joint, male, postural balance INTRODUCTION Balance is the ability to maintain the body’s center of gravity within the limits of the base of support with minimal sway or maximal steadiness,1-3 and the process by which postural stability is maintained or controlled within the limits of the base of support.4,5 In children, balance plays an important role in activities like playing, walking, reaching, and running. The maintenance of balance involves coordination of visual, vestibular, and somatosensory information. In early childhood, balance depends on the visual-vestibular system and slowly changes to depend on the somatosensory and 0898-5669\110/2602-0230 Pediatric Physical Therapy C 2014 Wolters Kluwer Health | Lippincott Williams & Copyright Wilkins and Section on Pediatrics of the American Physical Therapy Association
Correspondence: Abhijeet A. Deshmukh, BPTh, MPT, VSPM’S College of Physiotherapy, Lata Mangeshkar Hospital and Medical College, Digdoh Hills, Hingna Road, Nagpur 440019, Maharashtra, India ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.pedpt.com). The author declares no conflicts of interest. DOI: 10.1097/PEP.0000000000000031
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vestibular systems.4,5 Adult-like balance responses develop after the age of 6 years.4,6 Balance abilities can be divided into static and dynamic components. Static balance is defined as “the ability to maintain a posture such as balancing in standing or sitting,”5 and dynamic balance is defined as “the ability to maintain postural control during movements such as reaching for an object or walking on various surfaces.”7 Overall balance capability and postural stability increases and matures by 6 to 10 years of age.3,6 As balance improves in children, it allows them to perform activities of daily living independently.7 The somatosensory system is composed of the receptors and processing centers to integrate the sensory modalities such as touch, temperature, proprioception (body position, movement sensation and amount of forc generation), and nociception (pain).8 Proprioception, the acquisition of stimuli from conscious and unconscious processes in the sensorimotor system,9 is the process which underlies the ability to vary muscle contraction in immediate response to incoming information regarding external forces, by using all proprioceptive receptors surrounding joints and in the muscles to keep track of joint positions in the body.10 Proprioceptive sensory feedback is used by the central nervous system for conscious and unconscious appreciation of the position, movement, and force generated by the body and limbs. In patients with joint hypermobility, Pediatric Physical Therapy
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it has been suggested that proprioceptive acuity is altered.9,12,13 Joint hypermobility, that is, increased joint range of motion, is seen either as a localized condition, for example, in a single joint, or a more generalized one. When seen in parallel with musculoskeletal problems, the total condition is recognized as pathological and is called hypermobility syndrome.14,15 Instead of classifying hypermobility using range of motion in degrees, several authors used the presence of a certain extreme range of motion as a criterion for hypermobility. Previously used criteria for joint hypermobility have been revised, and currently the Beighton tests have gained international acceptance and seem to be the most widely used test today for diagnosing general joint hypermobility.14,16,17 Various tests are available to assess balance in children. Of the tests available, the Functional Reach (FR) and Lateral Reach (LR) Tests are commonly preferred for use in routine clinical and community settings. They are easy to understand, quickly performed, easy to score, and cost-effective, and no special equipment is required.4,9 The FR Test measures dynamic balance in a functional context of reaching forward.4,7,10 Functional reach, as developed and defined by Duncan et al,11 is the maximal distance one can reach forward beyond arm’s length while maintaining a fixed standing position. In children, the FR Test has been proposed as a discriminative test and as a diagnostic test to document feed-forward mechanisms of postural control,7,8 one of the components of the pediatric balance scale in school-aged children.4,7,8,10 Recent studies have been performed on the FR Test in India by Deshmukh et al4 and in western countries by Donahoe et al7 in school-aged children considered to be healthy and developing typically. The interrater, intrarater, and testretest reliability of the FR Test has been reported to be 0.98, 0.83, and 0.75, respectively.4,5,8 The LR Test measures postural stability in the mediallateral direction by assessing the maximum distance an individual can reach laterally beyond arm’s length at shoulder height, while maintaining a fixed base of support in the standing position.2,4,9,14 According to a previous study, lateral falls occur more frequently among the elderly population,18 leading to many complications; hence by measuring LR distance, medial-lateral stability can be assessed, which helps identify risk of falls, but this finding is not yet proved in children. The data for normal values of the FR Test and LR Test according to the studies carried out in India and Western countries are available. According to an Indian study, the normal value of the FR Test range from 22.7 (±3) to 37 (±4.4) cm and normal values for the LR Test range from 16.3 (±2.3) to 22.5 (±3.3) cm in children ranging in age from 6 to 12 years.4 Height contributes significantly among all the anthropometric measures, to both FR and LR Test values.4,7,18,19 The FR Test values proposed by Donahoe et al7 ranged from 21.17 to 32.79 cm for a similar age group in the United States.
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Despite recent studies of the FR and LR Tests in children aged 6 to 12 years, studies of FR and LR in those with joint hypermobility are lacking. Joint hypermobility is commonly seen in young children who are healthy, and is more common among girls than boys.12,14 The knee commonly displays hypermobility.13 Therefore, the aim of the study was to measure the FR and LR distance in school-aged children with knee joint hypermobility (KJH) of 10◦ hyperextension or more,20 and to examine their association with age, gender, and anthropometric factors. METHODS A cross-sectional study was performed using a multistage stratified sampling method. A total of 850 children were screened from 2 city schools. All the children from each class were screened for KJH, and of them, 10 subjects were selected from each class, using a random number table method. Consent and assent forms were obtained from all screened subjects. This was possible because of the cooperation of class teachers and school management, who generously had sent a recommendation letter for the study to all parents, and hence got approval from all parents, and therefore no subject replacement was needed in the study. A sample of 140 subjects (70 boys and 70 girls) within the age group of 6 to 12 years was selected from 2 schools. The subjects were divided into 7 subgroups depending on age, that is, 6, 7, 8, 9, 10, 11, and 12 years. Each subgroup had 20 subjects (10 boys and 10 girls). Children of both genders who had KJH were included. Children of both genders with typical development (TD) and between the ages of 6 and 12 years with the ability to stand for at least 2 minutes without support were included in the study. Children with any history of middleear infection within the past 6 months, any visual difficulties, any history of recent fractures of the lower limbs, and if height or weight fell below the 10th or above the 90th percentile for gender and age were excluded.4 PROCEDURE Approval from the scientific committee was obtained before the commencement of the study. Permission was taken from the Block Education Officer, and the list of schools was collected. Of 244 higher primary schools in the city, 2 schools were selected by simple random sampling using the random number table method. Permission was obtained from the school authorities to carry out the study. The classes where the target population was present were selected by lottery method. The subjects were selected on the basis of inclusion and exclusion criteria. The information sheet and the consent form were sent for the approval of the parents, and the assent form was completed by the subject. The subject was included in the study once the approval was received.
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The purpose of the study and the test procedure for FR and LR (Appendix available online as Supplemental Digital Content 1, http://links.lww.com/PPT/A60) was explained to teachers and the children. The test procedure was demonstrated to avoid compensatory activities. The demographic data of the subjects, that is, age and gender, were obtained from the school records. A weighing scale and a measuring stick were used to measure anthropometric data, including weight in kilograms and height in centimeters, respectively. The children were screened for KJH, which was defined as knee hyperextension of more than 10◦ for children20 and was measured bilaterally with the help of universal half-circle goniometer (Appendix available online as Supplemental Digital Content 1, http://links.lww.com/PPT/A60). The distance between the 2 acromion processes of the shoulders was used to define the base of support in the standing position (distance between 2 parallel feet).4 Each subject was given 3 successive trials of FR and LR separately. The mean value of these 3 trials was calculated and recorded.4 A 1-minute rest was given between the FR and LR Tests. See Figures 1 and 2. DATA ANALYSIS The Statistical Package for Social Science version 16.0 was used for data analyses. Descriptive statistics were obtained for normal values of the FR and LR Tests for all age groups along with the 95% confidence interval. Anal-
Fig. 2. Position for Lateral Reach Test.
ysis of variance was used to examine the relationship of age, gender, KJH, and base of support with the FR and LR Tests. Pair-wise comparisons for all the parameters were done using the Bonferroni test. RESULTS The values of FR for children with bilateral KJH ranged from 24.37 ± 1.97 to 28.77 ± 3.22 cm, and LR mean values ranged from 17.30 ± 0.97 to 19.20 ± 1.79 cm in the age group of 6 to 12 years. The demographic data of height, weight, body mass index, and base of support for boys and girls aged 6 to 12 years are given in Table 1. The means and SDs of height, FR distance, LR distance, and KJH angle among boys and girls from 6 to 12 years are shown in Table 2. Figures 3 and 4 show the mean FR and LR distance among boys and girls 6 to 12 years old. The Correlation of Mean FR and LR Distance With Mean KJH in Boys
Fig. 1. Position for Functional Reach Test. 232
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Table 3 shows the correlation of mean FR and LR distance with mean KJH angle in boys. The correlation coefficients for the FR and LR were 0.86 and −0.19, respectively. The FR distance among the boys showed a significant negative correlation, whereas LR distance showed no correlation with KJH angle. This means that as KJH increases, FR values decrease among boys but KJH is not related to LR values. Pediatric Physical Therapy
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TABLE 1 Demographic Data Age, y 6 7 8 9 10 11 12
Gender
Subjects, n
Height, Mean ± SD
Weight, Mean ± SD
Body Mass Index
Base of Support
Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls
10 10 10 10 10 10 10 10 10 10 10 10 10 10
106.70 ± 3.23 107.20 ± 2.10 120.90 ± 5.76 122.40 ± 4.03 120.30 ± 5.10 120.40 ± 2.88 128.10 ± 4.58 126.60 ± 3.84 134.70 ± 5.44 134.20 ± 5.67 141.80 ± 6.46 135.20 ± 7.54 139.80 ± 4.18 135.30 ± 6.27
16.50 ± 1.58 14.00 ± 1.05 18.80 ± 3.39 16.80 ± 1.62 18.60 ± 3.24 18.00 ± 1.33 26.90 ± 3.11 25.40 ± 3.47 27.10 ± 2.64 25.60 ± 2.01 30.90 ± 5.04 29.70 ± 4.11 38.10 ± 5.32 36.80 ± 3.05
14.69 12.28 13.05 11.35 12.91 12.5 16.50 16.07 15.13 14.30 15.60 16.31 19.74 20.21
26.00 25.90 27.30 27.40 27.50 27.20 28.20 28.80 31.30 31.30 28.80 27.40 28.70 28.70
TABLE 2 Height, Knee Joint Hypermobility Angle, FR Distance, and LR Distance Among Boys and Girls Aged 6 to 12 Years
Age, y 6 7 8 9 10 11 12
Gender
Subjects, n
Height, Mean ± SD, cm
Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls
10 10 10 10 10 10 10 10 10 10 10 10 10 10
106.70 ± 3.23 107.20 ± 2.10 120.90 ± 5.76 122.40 ± 4.03 120.30 ± 5.10 120.40 ± 2.88 128.10 ± 4.58 126.60 ± 3.84 134.70 ± 5.44 134.20 ± 5.67 141.80 ± 6.46 135.20 ± 7.54 139.80 ± 4.18 135.30 ± 6.27
Knee Joint Hypermobility Angle, Mean ± SD, ◦
FR Distance, Mean ± SD, cm
LR Distance, Mean ± SD, cm
14.70 ± 2.00 16.00 ± 2.16 14.30 ± 3.16 15.80 ± 2.85 14.10 ± 2.02 15.10 ± 3.11 14.00 ± 2.56 15.00 ± 3.00 13.90 ± 2.26 14.90 ± 2.62 13.80 ± 2.55 14.70 ± 2.58 13.70 ± 2.79 14.50 ± 2.59
24.37 ± 1.97 25.10 ± 2.16 25.47 ± 3.84 25.73 ± 2.94 26.13 ± 3.21 26.90 ± 3.40 27.27 ± 2.78 27.20 ± 3.49 28.03 ± 2.23 27.50 ± 2.32 28.07 ± 2.65 27.37 ± 2.75 28.77 ± 3.22 27.67 ± 2.65
17.30 ± 0.97 17.53 ± 1.32 17.77 ± 2.00 18.43 ± 2.56 17.85 ± 1.01 18.52 ± 1.96 17.90 ± 1.68 18.53 ± 1.85 18.32 ± 1.76 18.67 ± 2.31 18.60 ± 2.14 18.73 ± 1.53 19.20 ± 1.79 18.95 ± 1.87
Abbreviations: FR, functional reach; LR, lateral reach.
Fig. 3. Gender-wise comparison of mean values of functional reach distance with age.
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Fig. 4. Gender-wise comparison of mean values of lateral reach distance with age.
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TABLE 3 Correlation of FR Distance and LR Distance With Height and Knee Joint Hypermobility Angle Among the Boys and Girls Aged 6 to 12 Years FR Distance (6 to 12 y) Anthropometric Measures
LR Distance (6 to 12 y)
Analytical Values
Boys
Girls
Boys
Girls
r t P r t P
0.8973 4.43 .0068a −0.8680 3.19 .0113 b
0.899 4.60 .006a −0.9599 7.66 .0006a
0.2611 0.60 .57 b −0.1903 0.4334 .68
0.8595 3.75 .013 b −0.6534 1.93 .1115
Height
Knee joint hypermobility angle
Abbreviations: FR, functional reach; LR, lateral reach. a P ≤ .001. b P ≤ .05.
The Correlation of Mean FR and LR Distance With Mean KJH in Girls Table 3 shows the correlation of mean FR and LR values with the mean KJH angle in girls. The correlation coefficients for FR and LR were −0.95 and −0.65, respectively. The FR distance among the girls showed a significant negative correlation, while LR distance showed no significant correlation with KJH angle. This means that as KJH increases, FR values decrease among girls but does not show any relationship to LR values.
ues in both boys and girls, whereas the mean LR values showed a significant correlation only in girls. These results are in accord with the previous study.4 DISCUSSION The anthropometric measurements of the subjects included in the present study were in agreement with the Indian data4,21 for the same age groups. As shown in Table 4, the normal mean values for the FR ranged from 24.37 ± 1.97 to 28.77 ± 3.22 cm and LR
The Correlation of Mean FR and LR With Mean Height in Boys Table 3 shows the correlation of mean FR and LR with mean height in boys. The correlation coefficients for FR and LR were 0.89 and 0.26, respectively. The FR distance among the boys showed a significant positive correlation, whereas LR showed no significant correlation with height. This means that as height increases, FR values increase among boys but are not associated with LR values. The Correlation of Mean FR and LR With Mean Height in Girls Table 3 shows the correlation of mean FR mean LR with mean height in girls. The correlation coefficients were 0.89 and 0.85 for FR and LR, respectively. The FR distance among the girls showed a significant positive correlation with height, whereas LR distance showed a significant correlation with height. This means that as height increases, FR values increase among girls as do LR values.
Fig. 5. Gender-wise comparison of mean value of KJH angle with age.
Mean KJH Among Boys and Girls Figure 5 shows mean KJH for boys and girls 6 to 12 years of age, which demonstrates that as age increases, KJH decreases among girls more than boys. The results of the present study suggest that the lowerlimit values of FR and LR are similar, but higher limits showed lower values in subjects aged 6 to 12 years with hypermobility of the knee joint when compared with the data established by Deshmukh et al for children with TD.4 Height showed a significant correlation with mean FR val234
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TABLE 4 FRT and LRT Results in 3 Studies Study Present study Deshmukh et al4 Donahoe et al7
FRT, cm
LRT, cm
24.37 ± 1.97 to 28.77 ± 3.22 22.7 ± 3 to 37 ± 4.4 21.17 to 32.79
17.30 ± 0.97 to 19.20 ± 1.79 16.3 ± 2.3 to 22.5 ± 3.3 ...
Abbreviations: FRT, Functional Reach Test; LRT, Lateral Reach Test.
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mean values ranged from 17.30 ± 0.97 to 19.20 ± 1.79 cm in children from 6 to 12 years with KJH. The mean values proposed by Deshmukh et al4 for FR for a similar age group without hypermobility ranged from 22.7 ± 3.0 to 37 ± 4.4 cm and for LR ranged from 16.3 ± 2.3 to 22.5 ± 3.3 cm. The FR values proposed by Donahoe et al7 ranged from 21.17 to 32.79 cm for a similar age group in the United States. The values for FR and LR distance in this study among children 6 to 12 years with KJH are within the normal range, but they show a relatively reduced ability to achieve greater range when compared with children in the previous study.4 The results of this study reveal that FR and LR distances among boys and girls from 6 to 12 years are affected by factors such as height and KJH angle. Height is an important factor affecting FR and LR distance in children.4,7,18,19 The height of children in this study is less when compared with the previous study; hence, the values of FR and LR distance are relatively less in this study. In previous studies,9,12,13,22 it was found that knee joint proprioception becomes impaired in children with hypermobility syndrome and the children show weaker knee extensor and flexor muscles than healthy controls. In this study, children with knee joint hypermobility were included, which may have led to reduced joint proprioception and balance. Therefore, this could be a reason for relatively lower values of FR and LR distance. The effects of age, gender, height, base of support, and knee hyperextension angle were determined by using stepwise regression. Results showed that a direct correlation of height with FR and LR distance exists, which shows that as height increases, in both genders, a significant increase in FR distance is found, whereas LR distance increases significantly with height among girls alone. In this study, the knee hyperextension angle showed an inverse relationship with FR distance. As the hyperextension angle decreases, the FR distance increases in both boys and girls from age 6 to 12 years. Whereas, LR distance values showed no significant correlation with KJH in both boys and girls. This finding can be explained on the basis of the hypothesis that when anterior-posterior hypermobility present is in joints, FR will be more affected than LR. As in the present study, all children with knee hyperextension were included; hence one could expect this to affect forward reach alone rather than lateral reach. In this study, no children with defects in medial-lateral joint stability were included. Hence, it was found that the FR distance values were relatively less than in the previous study,4,7 and LR distance values did not show any significant relationship with the knee hyperextension angle in either gender. In this study, the children with generalized hypermobility as well as KJH alone were included. It has been shown previously that there is lack of joint control and proprioception in hypermobile joints, thus affecting balance.9,12,13,22 Thus, from the present study, it can be concluded that KJH among girls and height among both boys and girls are Pediatric Physical Therapy
the main contributing factors leading to variations in FR, and height among girls alone affects LR.
IMPLICATIONS FOR RESEARCH AND CLINICAL PRACTICE The result found in this study can be used as comparative data for assessment of balance impairments in children with KJH along with consideration of height. In this study, lower limb strength and joint position sense examinations were not completed, which could influence FR and LR values. Hence, in future research muscle strength of the lower extremity should be evaluated along with knee joint position sense. In this study, children with both generalized hypermobility and KJH alone were considered in one group. A comparative study between conditions of generalized joint hypermobility and localized KJH should be considered to allow greater accuracy in the evaluation of results. And, proprioception should be evaluated in these separate groups.
CONCLUSION In school-aged children, height and KJH contribute significantly to the FR values in both genders, whereas height contributes to LR values among girls alone.
REFERENCES 1. Emery C, Cassidy D, Klassen T, Rosychuk R, Rowe B. Development of a clinical static and dynamic standing balance measurement tool appropriate for use in adolescents. Phys Ther. 2005;85(6):502-514. 2. Horak FB. Clinical measurement of postural control in adults. Phys Ther. 1987;67(12):1881-1885. 3. Shumway-Cook A, Woollacott MH. Motor Control: Theory and Practical Applications. 4th ed. Baltimore, MD: Williams & Wilkins; 2010. 4. Deshmukh A, Sailaksmi G, Tedla J. Normal values of Functional Reach Test and Lateral Reach Test in Indian school children. Pediatr Phys Ther. 2011;23:1-8. 5. Westcott SL, Lowes LP, Richardson PK. Evaluation of postural stability in children: current theories and assessment tools. Phys Ther. 1997;77:629-645. 6. An M, Yi CW, Jeon H, Park S. Age-related changes of single-limb standing balance in children with and without deafness. Int J Paediatr Otorhinol. 2009;73:1539-1544. 7. Donahoe B, Turner D, Worrell T. The use of Functional Reach as a measurement of balance in boys and girls without disabilities ages 5 to 15 years. Pediatr Phys Ther. 1994;6:189-193. 8. Norris RA, Wilder E, Norton J. Functional Reach Test in 3 to 5 year old children without disabilities. Pediatr Phys Ther. 2008;20:47-52. 9. Callaghan M, Selfeb J, McHenry A, Oldham J. Effects of patellar taping on knee joint proprioception in patients with patellofemoral pain syndrome. Man Ther. 2008;13(3):192-199. 10. Hatzitaki V, Zisi V, Kollias I, Kioumourtzoglou E. Perceptual-motor contributions to static and dynamic balance control in children. J Mot Behav. 2002;34:161-170. 11. Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: a new clinical measure of balance. J Gerontol. 1990;45(6):M192-M197. 12. Mallik AK, Ferrell WR, McDonald AG, Sturrock RD. Impaired proprioceptive acuity at the proximal interphalengeal joint in patients with the hypermobility syndrome. Br J Rheumatol. 1994;33(7):631-637. Balance and Knee Hypermobility in Children
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13. Hall M, Ferrell R, Sturrock R, Hamblenf D, Baxendale R. The effect of the hypermobility syndrome on knee joint proprioception. Br J Rheumatol. 1995;34(2):121-125. 14. Juul-Kristensen B, Rogind H, Jensen D, Remvig L. Inter-examiner reproducibility of tests and criteria for generalized joint hypermobility and benign joint hypermobility syndrome. Rheumatology. 2007;46:1835-1841. 15. Carter C, Wilkinson J. Persistent joint laxity and congenital dislocation of the hip joint. J Bone Joint Surg. 1964;46:40-45. 16. Corben T, Lewis J, Petty N. Contribution of lumbar spine and hip movement during the palms to floor test in individuals with diagnosed hypermobility syndrome. Physiother Theory Pract. 2008;24(1):1-12. 17. Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Ann Rheum Dis. 1973;32:413.
18. Takahashi T, Ishida K, Yamamoto H, et al. Modification of the Functional Reach Test: analysis of lateral and anterior functional reach in community-dwelling older people. Arch Gerontol Geriatr. 2006;42:167-173. 19. Habib Z, Westcott S. Assessment of anthropometric factors on balance tests in children. Pediatr Phys Ther. 1998;10:101109. 20. Russek LN. Hypermobility syndrome. Phys Ther J. 1999;79(6):591599. 21. Parthasarathy A, Menon PSN, Gupta P, Nair MKC. Growth and development. In:Agarwal KN, ed. IAP Textbook of Pediatrics. 4th ed. New Delhi, India: Jaypee Brothers; 2009:94. 22. Fatoye F, Palmer S. Proprioception and muscle torque deficits in children with hypermobility syndrome. Rheumatology. 2009;48(2):152157.
CLINICAL BOTTOM LINE Commentary on “Normal Values of Functional Reach and Lateral Reach Tests in Children With Knee Joint Hypermobility”
“How could I apply this information?” The author suggests that hypermobility may negatively affect performance on the Functional Reach and Lateral Reach Tests. In this study, schoolchildren from India with increased knee hypermobility reached a shorter distance on the Functional Reach Test. In addition, taller boys and girls reached a longer distance on the Functional Reach Test and taller girls reached further on the Lateral Reach Test. The data suggest that hypermobility has a negative effect on functional balance especially when reaching forward. The clinician may find it helpful, when assessing balance in children, to evaluate knee joint hypermobility. Information gained from using both of these clinical measures together may provide information about underlying mechanisms of postural control as well as balance. This information will assist the clinician in identifying and providing more focused intervention aimed at increasing functional balance when treating children with excessive range of motion at the knee. “What should I be mindful about when applying this information?” The participants in the study are from India and, as the author stated, the functional reach norms from India are different from the norms from the United States. Therefore, the distances reached in this study may not be directly applicable to children outside India. In addition, these measurements were taken on a population developing typically. Other factors, which may affect a child’s balance when performing the Functional Reach Test (such as forefoot pronation, hip alignment [anteversion], and muscle strength), were not considered. As a consequence, clinicians should be cautious when drawing conclusions and designing treatment strategies for children with knee joint hypomobility. Treatment strategies should not be developed without considering additional information such as postural alignment, lower extremity muscle strength, and proprioceptive awareness. Although an analysis of variance was used, the author reported only correlational data and not differences between groups. Because of the design of the study, we cannot say that hypermobility causes the test results, only that the 2 findings are related. Further research on children with hypermobility linked to a developmental diagnosis is needed.
Julia Looper, PT, PhD University of Puget Sound, Tacoma, Washington Penny Coyner, PT, MPT, PCS Northwest Pediatric Therapies, Issaquah, Washington The authors declare no conflicts of interest. DOI: 10.1097/PEP.0000000000000032
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