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Pediatric Physical Therapy:
doi: 10.1097/PEP.0b013e3182099192
Research Article

Normal Values of Functional Reach and Lateral Reach Tests in Indian School Children

Deshmukh, Abhijeet A. MPT; Ganesan, Sailaksmi MPT, PhD; Tedla, Jaya Shanker MPT

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Department of Physiotherapy, Kasturba Medical College, Mangalore, Karnataka, India.

Correspondence: Abhijeet A. Deshmukh, MPT, Department of Physiotherapy, Kasturba Medical College (Manipal University), Bejai, Mangalore, Karnataka 575004, India ().

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Abstract

Purpose: To establish normal values for functional reach (FR) and lateral reach (LR) in school children and to study the correlation of anthropometric measures with FR and LR values and the association between FR and LR scores.

Methods: A total of 350 children aged 6 to 12 years were randomly selected. Three successive trials of FR and LR with the child standing with feet shoulder width apart were performed and the mean of 3 trials was calculated.

Results: Normal values of FR and LR were obtained. Pearson product moment correlation was used to examine the association of FR and LR to age, gender, and anthropometric measures. Stepwise regression analysis was done to obtain normal values of FR and LR with respect to height. Functional reach values significantly predicted LR values and vice versa.

Conclusion: Normal mean values of FR and LR range from 22.7 cm to 37 cm and 16.3 cm to 22.5 cm, respectively. Height significantly correlates with both FR and LR.

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INTRODUCTION

Balance is the process by which postural stability is maintained or controlled over the base of support.1 In normal development, the growth of postural stability proceeds in a cephalocaudal direction. An infant achieves head control first, then the trunk, and finally postural stability in standing. Overall balance ability and postural stability increase and mature by 6 to 10 years of age.2,3

In children, balance plays a very important role in many activities, including playing, walking, reaching, and running in different environments such as school, home, and community. These activities involve both the static and dynamic components of balance. In early childhood, balance primarily depends on the visual-vestibular system, which slowly changes to dependence on the somatosensory-vestibular system.1 However, adult-like responses require more than 6 years to develop.3 With age, balance improves in children, which allows them to perform daily activities independently. The quality of reaching also improves, which depends on the adequacy of postural stability.4

Problems in postural stability and balance are common in children with sensory impairments like visual, proprioceptive, and vestibular deficits and also in children with developmental disabilities, such as cerebral palsy.1,2,5 Such problems cause serious functional consequences: for example, falls resulting in reduced mobility and increased disability and morbidity.6 A child with an impairment of postural stability is more dependent on a caregiver, and as age advances, the impairment may lead to severe participation restriction in the community.5

Therefore, balance examinations are important components of a physical therapy assessment to screen for balance impairments in children and to predict the child's ability to safely and independently function in a variety of environments.5 In the medical field, various tools are available to measure and detect balance impairments in children. Whereas some tests specifically evaluate balance,1 others assess more generalized gross motor functions that include balance components.1,7

Despite the many tests available, tests of functional reach (FR) and lateral reach (LR) are presently preferred for use in routine clinical and community settings, because no special equipment is required. They are easy to understand, quickly performed, easy to score, and relevant to a variety of functional situations.8,9 Clinical measurements of FR and LR are intended to assess dynamic balance.2,7,8

The FR Test (FRT) is measured as the maximal distance an individual can reach forward beyond arm length at shoulder height, while maintaining a fixed base of support in the standing position.7,10 Functional reach is one of the components of the Pediatric Balance Scale for school-age children, which is a modified version of the Berg Balance Scale.5 This measurement tool is quantitative. It can be easily used for both adults and children with and without disabilities.7,9 The interrater, intrarater, and test-retest reliability of the FRT has been reported to be 0.98, 0.83, and 0.75, respectively.1,7 Normative data for this measurement tool have been developed on subjects aged 20 to 80 years in the United States7,9,11 and for subjects aged 18 to 30 years and 65 to 86 years in Japan.11,12

The LR Test (LRT) measures postural stability in the medial-lateral direction by assessing the maximum distance an individual can reach laterally beyond arm length at shoulder height, while maintaining a fixed base of support in standing.7,8 Studies have found that lateral falls occur more frequently and lead to various complications. Hence, it is important to assess mediolateral stability by measuring LR distance in children to identify risk of falling.13 However, in the current literature, normal values for LR are not available for children.

Several factors interact with balance abilities in children: age, gender, height, weight, and base of support. Studies by Habib and Westcott14 found that height, weight, and base of support were important variables affecting balance abilities in young children. Their results suggest that height is a more important predictor of FR than base of support.

Height and weight of children reflect the process of growth and development, but these data are cross-sectional. Variations exist between countries with respect to height, weight, and anthropometric findings. Thus, variations in these factors will play an important role in both FRT and LRT distance values.15

For Western populations, normative data are available in young adults and elderly people for both the FRT and the LRT and in children for the FRT. However, in India, normative data for both the FRT and the LRT are not available for children. Therefore, to use balance tests effectively for children in India, test norms must be established in large samples across all age groups of the healthy population. Identification of norms allows identification of balance problems permitting early intervention targeting specific impairments. To date, there are no normal values published for the LRT in children in both the Western and Indian population, and normal values are available only for the FRT in the United States.

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PURPOSE

In this study, we aimed to establish normal values for the FRT and LRT in school-age children,16 to find the effects of age, gender, and anthropometric measurements on FR and LR distances and to see whether there is any significant correlation between values of FR and LR distances.

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METHODS

A cross-sectional study was performed using a multistage stratified sampling method. A sample of 350 subjects within the age range of 6 to 12 years was selected from 2 schools of Mangalore city. There were 175 subjects of each gender in the sample.

Subjects were divided into 7 subgroups depending on age, that is, 6, 7, 8, 9, 10, 11, and 12 years. Subjects in the 6-year-old group included children between their sixth birthday and 1 day before their next birthday, and the other subjects were divided into similar age groups. Each subgroup had 50 subjects (25 boys and 25 girls). Children of both genders who were developing typically 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 middle-ear infection within the past 6 months9 or with height or weight below the 10th or above the 90th percentile for gender and age9 as well as those who were uncooperative were excluded from the study.

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Procedure

Approval from the scientific committee and the time bound research ethics committee was obtained prior to the commencement of the study. Permission was obtained from the block education officer and the list of schools was collected.

Out of 180 higher primary schools of Mangalore city, 2 schools were selected by simple random sampling using 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 and 25 subjects were selected from each class using a computer-generated random number table. 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 their parents, and the assent form was completed by the subject. Once the approvals were received, the subject was included in the study.

The purpose of the study and the test procedure for FR and LR (Appendix) was explained to the children. Test procedures were demonstrated to avoid compensatory activities. The demographic data of the subjects, that is, age and gender, were obtained from the school records. Anthropometric measurements such as weight in kilograms and height in centimeters were measured using weighing and measuring scales, respectively. Upper extremity length was measured in centimeters from the tip of the acromion process to the tip of the middle finger in supine lying with the shoulder in the neutral position by the side of the body, elbow extended, forearm pronated, wrist in neutral, and fingers extended. Similarly, lower extremity length was measured in centimeters from the anterior superior iliac spine to the tip of the medial malleolus in supine lying with hip in the neutral position, knee extended, and ankle in neutral. The distance between the 2 acromion processes of the shoulders was taken as a reference for the base of support in the standing position (distance between the 2 parallel feet).10–12

Each subject was given 3 successive trials of FR and LR separately (Figures 1 and 2). The mean value of these 3 trials was calculated and recorded.9 One-minute rest was given between the FRT and LRT.

Figure 1
Figure 1
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Figure 2
Figure 2
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Data Analysis

The Statistical Package for Social Science (SPSS; SPSS Inc, Chicago, Illinois) Version 16.0 was used for analysis. Descriptive statistics were obtained for normal values of the FRT and LRT for all age groups, and 95% confidence intervals were determined. Pearson product moment correlation was used to examine associations between age, gender, height, weight, base of support, and length of the upper and lower extremity.

Further regression analyses were performed to assess effect of various parameters on FRT and LRT. A stepwise regression analysis was done to obtain normal values of the FRT and LRT with respect to height.

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RESULTS

The demographic data of subjects are given in Table 1. The means and standard deviations of FR and LR distances and their correlations with anthropometric parameters are shown in Table 2. The normal values of FR ranged from 22.7 cm (± 3 cm) to 37 cm (± 4.4 cm) and of LR ranged from 16.3 cm (± 2.3 cm) to 22.5 cm (± 3.3 cm).

Table 1
Table 1
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Table 2
Table 2
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Regression analyses to assess the effect of various parameters on the FRT and the LRT are shown in Tables 3 and 4, respectively. The means and standard deviations of FR and LR distances according to height and age are shown in Table 5.

Table 3
Table 3
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Table 4
Table 4
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Table 5
Table 5
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Correlations of FRT and LRT With Anthropometric Measures

The Correlation of FRT and LRT Results With Age and Gender

With reference to age, the FR distance showed increments in both genders except for ages 8, 10, and 11 years, as the values were nearly similar (Figure 3). Similarly, with reference to age, the LR distance showed increments in both genders except for ages 9 and 11 years, as the values were nearly similar (Figure 4).

Figure 3
Figure 3
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Figure 4
Figure 4
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The Correlation of FRT and LRT Results With Height

The FR distance for girls showed a highly significant correlation with height for ages 6, 7, 9, and 10 years and a significant correlation for ages 11 and 12 years. However, among boys, the FR distance showed a highly significant correlation for ages 9 and 10 years and a significant correlation for age 7 years only. The LR distance among girls showed a highly significant correlation with height for ages 6 and 9 years and a significant correlation for ages 7 and 10 years and among boys a significant correlation for ages 7 and 12 years only.

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The Correlation of FRT and LRT Results With Weight

The FR distance among girls showed a highly significant correlation with weight for age 9 years and a significant correlation for ages 6 and 7 years only. For boys, weight showed a highly significant correlation for age 9 years and a significant correlation for age 10 years. The LR distance among girls showed a highly significant correlation with weight for age 9 years and a significant correlation for age 6 years only. For boys, the correlation was highly significant for age 7 years only.

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The Correlation of FRT and LRT Results With Length of the Upper Extremity

The FR distance among girls showed a highly significant correlation with length of the upper extremity for ages 6, 7, and 10 years and a significant correlation for age 9 years. Among boys, there was a highly significant correlation for ages 7 and 9 years only.

The LR distance showed a highly significant correlation for girls with length of the upper extremity for ages 6 and 9 years. On the contrary, among boys, there was no correlation between LR distance and length of the upper extremity for any of the age groups.

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The Correlation of FRT and LRT Results With Length of the Lower Extremity

The FR distance among girls showed a highly significant correlation with the length of the lower extremity for ages 6, 7, 8, and 10 years and a significant correlation for ages 9 and 12 years. However, boys showed a highly significant correlation for age 9 years and a significant correlation for age 11 years only. The LR distance for girls showed a highly significant correlation with length of the lower extremity for ages 6 and 9 years only, and for boys there was a significant correlation for age 11 years only.

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The Correlation of FRT and LRT Results With Base of Support

The FR distance showed a significant correlation among girls with base of support for ages 8 and 9 years, and in boys, a highly significant correlation was found for age 11 years and a significant correlation for ages 9 and 10 years. The LR distance among girls showed a significant correlation with base of support only for age 9 years, and among boys, there was highly significant correlation for age 7 years and a significant correlation for age 10 years only.

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Correlation Between FR and LR Distance Values

In the present study, it was found that for children aged 6 to 12 years, the FR mean distance value could be significantly predicted by the LR mean distance values (R2 = 0.32) and vice versa in both genders by using the following formulas:

FR mean (cm) = 11.07 + [0.96 × LR mean (cm)], (R2 = 0.32)

LR mean (cm) = 9.65 + [0.34 × FR mean (cm)], (R2 = 0.32)

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DISCUSSION

The anthropometric measurements of the subjects included in the present study were in agreement with the Indian data for the respective age groups.16 The normal mean values for the FRT ranged from 22.7 cm to 37 cm and LRT mean values ranged from 16.3 cm to 22.5 cm in children 6- to 12-years-old. The FRT values proposed by Donahoe et al9 ranged from 21.17 cm to 32.79 cm for a similar age group in United States. When these values were compared with the results of the current study, it was found that FRT values for the 6-year-old age group in the present study showed slightly higher mean values, but the mean difference was greater in the 12-year-old age group. This result may be due to both the difference in when the growth spurt occurs and cross-sectional variation among children from different countries.15

The results of the current study found that FRT values among girls were affected by factors such as height and lengths of the upper extremity and lower extremity, whereas in boys, only height was an important factor affecting FRT values in most of the age groups. The base of support was shown to be a significant factor only for age groups between 8 and 10 years in both genders. For the LRT results, height was seen to be an important factor among girls.

The effects of age, gender, height, weight, length of the upper extremity, length of the lower extremity, and base of support on FR and LR were determined by using stepwise regression. Results showed the FRT was significantly affected by height among girls but not among boys. This finding is in agreement with other published data.9,14 Habib and Westcott14 found height to be an important factor affecting FRT scores in Pakistani children aged 5 to 7 years. This gender difference observed in height may be due to variation in the timing of growth spurts or puberty in both boys and girls, which occurs earlier in girls, that is, by ages 8 to 13 years and in boys, by ages 9 to 14 years.16 In the intervening years of middle childhood (6 to 10 years for girls and 6 to 12 years for boys), somatic growth velocity is relatively slow compared to body growth, which is more rapid during puberty.16 Thus, if height is below the 10th or above the 90th percentile for age and gender, it may affect FRT and LRT results. As a result, early-maturing, taller children may show higher values, whereas slow-growing children with short stature at a given age will show lower values in these tests.

In the current study, both the length of the upper and lower extremity showed a high correlation with the FRT among girls but not among boys, which partially agreed with the findings of Donahoe et al,9 who reported only arm length correlated with the FRT results. According to Tacar et al,17 upper and lower extremity lengths increase in parallel to height, which may explain the results of the present study, wherein a high correlation of the lengths of the upper and lower extremities with FRT results was observed only in girls. This could be due to the influence of a significant increase in height in girls compared to boys. In this study, the upper and lower extremity lengths did not contribute to the LRT values in either gender.

Results showed that weight did not contribute to any significant change in FRT or LRT values in either gender, which contradicts the findings of Norris et al.7 According to their study, the only significant predictor of FRT distance was weight, which accounted for 34% of the variance in FRT results. This finding was supported by Ledin et al,18 who found that postural control was substantially affected by 20% additional body weight. In the present study, the subjects fell within the standard ranges of weight for their age,16 and hence, weight of the subjects did not show a significant correlation with FRT results. Therefore, variation in reach distance might be expected in children who are obese across different ages and gender.

The base of support showed a correlation with FRT results among girls at 8 and 9 years and in boys at 9, 10 and 11 years, which was in accord with the findings by Volkman et al,15 wherein they found that FRT values were affected by base of support in children aged 8 to 10 years. In the present study, the base of support was defined as shoulder width, that is, the distance between the 2 acromion processes. Variation in shoulder width could be expected with body growth. In humans, growth is cephalocaudal in direction, that is, head, neck, arms, trunk, and legs, and as age increases, the height and the width of trunk also increase.18 Hence, it could be concluded that shoulder width will also increase with age, and so would the base of support. The correlation of base of support with FRT results may be due to the occurrence of growth in children of both genders aged 8 to 10 years. It could be concluded that subjects using a self-selected base of support while performing the FRT or LRT will affect reach values.

It was observed in the present study that the FRT values were greater than the LRT values across the age group of 6 to 12 years. During the FRT, the subject was able to receive visual feedback and hence could reach the yardstick more easily as compared to the LRT, where the subject was not permitted to rotate the head. Because the visual feedback was blocked, the subject had to reach sideways with increased dependency on the somatosensory system to maintain balance, as the vestibular system is considered to be immature in this age group.1,3 Hence, visual feedback may have increased the reaching ability in the FRT, which is also supported by the study done by Loram.19

The biomechanical factors of reach strategies10 and range of motion available at the ankle joint also affect the FRT and LRT. During reach, more range of plantar flexion and dorsiflexion compared to inversion and eversion will allow more anterior-posterior excursion during the FRT than medial-lateral excursion during the LRT. It has also been proposed that during the FRT, more ankle and hip strategies or mixed strategies are used,10 which could help increase the reaching distance in the FRT but not the LRT, as leaning ability in mediolateral excursion is less than anterior-posterior excursion.20

It was also found that the FRT showed a very strong association with the LRT such that the LRT value can be predicted easily when the FRT value is known and vice versa. When the distance of the FRT was compared with that of the LRT, results showed that FRT distance values were significantly higher than LRT distance values in both genders from ages 6 to 12 years. Children were more dependent on visual inputs to maintain balance and out of the 3 sensory inputs; the vestibular system seemed to be the least effective in postural stability predominantly in early childhood.1,3 Jbabdi20 found that elderly people were able to reach only 72% of the mean theoretical limit of stability in the forward direction and 54% of the mean limit in both lateral directions.

Thus, from the present study, it can be concluded that height is the main contributing factor leading to variations in FRT and LRT distance, because parameters such as length of the upper and lower extremity and base of support showed direct correlations with growth.

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IMPLICATIONS FOR RESEARCH AND CLINICAL PRACTICE

The normal values obtained in this study can be used as baseline data for assessment of balance impairments in Indian children. Predicted mean FRT and LRT values were obtained in present study, which allows one to calculate either values if one of the reach values is known. The limitation of the study was that subjects were permitted to use the lower limb strategies of their choice during the FRT and LRT, which may have affected the reach distance. For future research, the strategies adopted by the child during both the FRT and LRT should be evaluated and the reliability and validity of the FRT and LRT in children with specific balance impairments should be examined.

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CONCLUSION

The normal values of the FRT range from 22.7 cm (±3 cm) to 37 cm (±4.4 cm) and normal values for the LRT range from 16.3 cm (±2.3 cm) to 22.5 cm (±3.3 cm) in Indian children ranging in age from 6 to 12 years. Among all the anthropometric measures, height contributes significantly to both FRT and LRT values.

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REFERENCES

1. Westcott SL, Lowes LP, Richardson PK. Evaluation of postural stability in children: current theories and assessment tools. Phys Ther. 1997;77:629–645.

2. Robinson MW, Krebs DE, Giorgetti MM. Functional reach: does it really measure dynamic balance? Arch Phys Med Rehabil. 1999;80:262–269.

3. 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.

4. van der heide JC, Fock JM, Otten B, Stremmelaar E, Hadders-algra M. Kinematic characteristics of postural control during reaching in preterm children with cerebral palsy. Pediatr Res. 2005;58:586–593.

5. Franjoine MR, Gunther JS, Taylor MJ. Pediatric balance scale: a modified version of the berg balance scale for the school-age child with mild to moderate motor impairment. Pediatr Phys Ther. 2003;15:114–128.

6. Benvenuti F, Mecacci R, Gineprari I, et al. Kinematic characteristics of standing disequilibrium: reliability and validity of a posturographic protocol. Arch Phys Med Rehabil. 1999;80:278–287.

7. 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.

8. Brauer S, Burns Y, Galley P. Lateral reach: a clinical measure of mediolateral stability. Physiother Res Int. 1999;4:81–88.

9. Donahoe B, Turner D, Worrell T. The use of functional reach as a measurement of balance in boys and girls without disabilities 5 to 15 years. Pediatr Phys Ther. 1994;6:189–193.

10. Liao CF, Lin SI. Effects of different movement strategies on forward reach distance. Gait Posture. 2008;28:16–23.

11. Kage H, Okuda M, Nakamura I, Kunitsugu I, Sugiyama S, Hobara T. Measuring methods for functional reach test: comparison of 1-arm reach and 2-arm reach. Arch Phys Med Rehabil. 2009;90:2103–2107.

12. Kage H, Okuda M, Nakamura I, Kunitsugu I, Sugiyama S, Hobara T. Comparison of the one-arm and two-arm Functional reach test in young adults. J Phys Ther Sci. 2009;21:207–212.

13. 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.

14. Habib Z, Westcott S. Assessment of anthropometric factors on balance test in children. Pediatr Phys Ther. 1998;10:101–109.

15. Volkman K, Stergiou N, Stuberg W, Blanke D, Stoner J. Factors affecting functional reach scores in youth with typical development. Pediatr Phys Ther. 2009;21:38–44.

16. 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.

17. Tacar O, Dogruyol S, Hatipoglu ES. Lower and upper limb length of urban and rural 7-11 years old Turkish school children. Anthropol Anz. 1999;57:269–276.

18. Ledin T, Fransson PA, Magnusson M. Effects of postural disturbances with fatigued triceps surae muscles or with 20% additional body weight. Gait Posture. 2004;19:184–193.

19. Loram ID, Kelly SM, Lakie M. Human balancing of an inverted pendulum: is sway size controlled by ankle impedance? J Physiol. 2001;532, 879–891.

20. Jbabdi M, Boissy P, Hamel M. Assessing control of postural stability in community-living older adults using performance-based limits of stability. BMC Geriatr. 2008;8:8.

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APPENDIX

Test Procedure

Functional Reach Test

1. Child was made to stand without footwear on the floor with the right shoulder parallel to the wall.

2. Child's acromion process was palpated and the ruler was adjusted on the wall to the level of the acromion process, parallel to the floor.

3. Child was asked to raise the arm horizontally (approximately, 90 degree of shoulder flexion), so that it was level with the ruler. The elbow was in extension; forearm in pronation, wrist in neutral, and fingers extended.

4. Contralateral extremity was held in neutral position, relaxed by the side of the body.

5. The relation of the tip of the extended middle finger to that of the ruler marking was noted as the initial reading.

6. The child was then asked to reach as far as possible in the direction of the flexed upper extremity with both feet firmly on ground, without using strategies or loosing balance such as stepping forward, touching the wall, or receiving assistance from the investigator.

7. The total displacement of the tip of the middle finger (in centimeters) against the ruler between the starting and ending position was noted. End position was held for 3 seconds. This distance was noted as the child's functional reach distance.

8. A total of 3 trials were given for the functional reach and the distance was measured. The average of these 3 values was recorded as functional reach distance. A 5-second rest was given between each trial.

Lateral Reach Test

1. Child was made to stand on the floor without footwear with his or her back toward the wall but not making contact with it.

2. Child's acromion process was palpated and the ruler was adjusted on the wall to the level of the acromion process, parallel to the floor.

3. Child was asked to abduct his or her shoulder, so that it was level with the ruler. The elbow was in extension, forearm in pronation, wrist in neutral, and fingers extended.

4. Contralateral extremity was held in neutral position, relaxed by the side of the body.

5. The relation of the tip of the extended middle finger to that of the ruler marking was noted as the initial reading.

6. The child was asked to reach as far as possible in the direction of the abducted extremity with both feet firmly on ground, without using strategies or loosing balance such as stepping, raising heels, or trunk rotation/flexion.

7. The total displacement of the tip of the middle finger (in centimeters) against the ruler between the starting and ending position was noted. End position was held for at least 3 seconds. This distance was noted as the child's lateral reach distance.

8. A total of 3 trials were given for the side and the distance was measured. The average of these 3 values was recorded as a lateral reach distance. A 5-second rest was given between each trial.

Age factors; body weight; child; female; gender; height; male; postural balance

© 2011 Lippincott Williams & Wilkins, Inc.

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