Previous publications have introduced both the concept of and the need for common diagnostic language among physical therapists (PTs) that will drive intervention and assist with prognostication.1–5 Hislop6 is frequently credited with issuing the call to action in this area with her 1975 Mary McMillan lecture. The House of Delegates passed a motion in 1984 that was the basis for the American Physical Therapy Association's (APTA's) position that “Physical therapists shall establish a diagnosis for each patient/client.”7 Following the 2004 John P. Maley Lecture by Cynthia Zadai,4 the PT faculty at Washington University took up the challenge of diagnosis by PTs and have since led the way for the profession in this arena. Their initiative ultimately led to the first “Diagnosis Dialog” meeting, held in St Louis, Missouri, in 2006. This meeting was an invitational conference of recognized experts across the profession of physical therapy. Currently, Barbara Norton, a member of the PT faculty at Washington University, continues to lead the Diagnosis Dialog group, which has expanded its initial work by reaching out to APTA Sections and others and inviting them to join the conversation.
In 2009, the work of the Diagnosis Dialog group was discussed by the Section on Pediatrics Board of Directors and the decision was made to form a Diagnosis Task Force that was charged to “explore the role and scope of diagnosis in pediatric physical therapy.” The task force consisted of Ann Van Sant, a member of the Diagnosis Dialog group; Kathy Martin, Section on Pediatrics Region III Director; and Executive Committee representative, Sarah Westcott McCoy. Initially this group conceptualized the task as exploring both the process and the product of establishing diagnostic labels. Very early in our work, we realized that the process could involve multiple strategies that could be applied by PTs in any specialty practice area. Brian Wrotniak then joined the group to help with the process and to develop a specific diagnosis that identified movement system dysfunction associated with obesity in children. Following the lead of the Diagnosis Dialog group, the task force members agreed that a “diagnosis” should be a syndrome describing a human movement system dysfunction. More specifically, the diagnosis identified by a pediatric PT should be a collection of signs (physical manifestations identified in an examination) and symptoms (things reported by the patient), and at a minimum the diagnosis should guide the selection of intervention strategies, and ultimately contribute to the prognosis.
The value of PTs developing common language for diagnosis of human movement system dysfunction has been clearly articulated by the Diagnosis Dialog group.8 A diagnosis by a physician is often based in cellular pathology; however, because PTs rarely provide treatments directed at cellular pathology, the physician's diagnosis is often of minimal assistance, as it does not identify the movement disorders that will be addressed by the PT with appropriate intervention strategies. The purpose of developing diagnostic language for the human movement system is to categorize signs and symptoms that will drive the selection of the most effective intervention and, in some instances, be linked to prognosis for functional recovery. Jette wrote that “What differentiates diagnosis by the PT from diagnosis by the physician is not the process itself but the phenomena that are being observed and classified.”3(p967) He also stated that our ability to classify and measure clinical phenomena important to our scope of practice is critical to the PT profession's development of a scientific basis.
Reflective PTs with sufficient practice experience routinely use pattern recognition within the human movement system in their examinations and assessments, but we have been reticent to identify those patterns as diagnoses. This reticence is likely a remnant of our early practice when prescriptions for intervention were provided by physicians. Thus PTs are routinely identifying aspects of human movement that go beyond the diagnosis provided by physicians. In summary, this recognition of patterns of human movement system dysfunction and the development of common language to label identified syndromes are the process and product of diagnosis by PTs. The purpose of this article was to clarify what diagnosis means for pediatric PTs, to provide several examples of human movement dysfunction syndromes, and to offer guidance for how pediatric PTs may continue this work in any clinical setting.
DIAGNOSIS—POINTS OF CONSENSUS
Although some difference of opinion continues among the original Diagnosis Dialog group members,9 many areas of consensus have been reached in the past decade. These areas of consensus as they relate to pediatric PT are described here.
First and foremost, the term “diagnosis” should be used without qualification. Physical therapists are qualified to develop a diagnosis within their scope of practice and the term itself refers to a collection of signs and symptoms of human movement system dysfunction. The diagnosis should not be called a “physical therapy diagnosis” because the purpose of the diagnostic label is to describe the movement system dysfunction and to guide intervention, not to convey ownership. The diagnosis of a human movement system dysfunction is not unique to PT as other practitioners could be expected to recognize the same signs and symptoms.1 The movement system diagnosis is not meant to replace the diagnosis derived by a physician, but it does need to be specific enough to guide physical therapy intervention. As a result, each child may have multiple diagnoses, each one conveying specific information about different aspects of the child's needs.
Second, the diagnosis should be based in the human movement system and represents signs that occur together, thus comprising a syndrome. Focusing on the human movement system ensures that the PT making the diagnosis functions within our scope of practice and that the diagnosis is relevant to selecting PT intervention strategies. The syndrome should also be significant enough to trigger an episode of care; otherwise, a PT would not be involved. This leads to a related point of consensus among the Diagnosis Dialog participants, specifically, the diagnosis should be described in commonly accepted terminology and not professional jargon, or eponyms that honor an individual, such as Down syndrome.
Finally, the Diagnosis Dialog group has stated that models of disablement, like the International Classification of Disability, Function and Health,10 should not drive the diagnoses as such models change over time. Rather than tying diagnostic language to a specific model that would have to be changed each time a new model of health is developed, movement system diagnoses should be based on evidence from the research literature whenever possible.
The template for developing a diagnosis has been included as Appendix 1. This template was developed by the Diagnosis Dialog group and was meant to guide PTs through the development of a human movement system diagnosis. The questions within the template are meant to assist with pattern recognition and identification of evidence-based strategies for examination. The template was designed to cover broad areas and to be applicable across many settings and patient types; thus, some items may not be relevant in all instances.
In pediatrics, the Diagnosis Task Force believes that the diagnosis, when appropriate, should convey the relationship of age to the syndrome. For some conditions seen by pediatric PTs, the human movement system dysfunction changes over time and would differ in specific age ranges.
To help illustrate how these concepts are applied to pediatric PT, we have developed 3 examples, each using a slightly different process to arrive at a human movement system diagnostic label.
Hypotonia syndrome is defined as a human movement system syndrome characterized by decreased strength, increased flexibility/muscle extensibility, hypermobility, decreased activity tolerance, delayed motor abilities or skills, leaning on supports, and rounded shoulder posture (Appendix 2). This diagnosis was identified through a series of 2 surveys of pediatric PTs and occupational therapists (OTs). The first survey sought to identify common clinical characteristics of children with hypotonia,11 and the second survey sought to identify level of agreement with those findings within a larger participant pool.12
The initial survey was sent to 150 PTs and 150 OTs.11 The response rate was 26.6%, and the majority of respondents had more than 10 years of experience and worked in either outpatient or school-based settings. The survey asked the respondents to identify characteristics of children with hypotonia in 5 categories: strength, endurance, mobility, flexibility, and posture. Open-ended responses were coded and “consensus” on a characteristic was defined as it being mentioned by at least 25% of respondents in each discipline. Eight characteristics were identified, including the 7 noted previously in the definition of hypotonia syndrome and an additional characteristic of poor attention and motivation.
The next step was to confirm these characteristics by sending a second survey to a larger sample (500 from each discipline).12 The response rate (26.8%) and demographics were similar to the first survey, and respondents were asked to use a 5-point Likert scale to indicate their level of agreement that children with hypotonia displayed each of the 8 characteristics. At least two thirds or more of the respondents either agreed or strongly agreed that children with hypotonia exhibited 7 of the 8 characteristics. However, nearly one third of the respondents either disagreed or strongly disagreed that the eighth characteristic, poor attention and motivation, was present in children with hypotonia. In addition, respondents were asked to rank the 8 characteristics in order of their prevalence. Hypermobile joints, increased flexibility/muscle extensibility, and decreased strength emerged as the top 3, whereas poor attention and motivation was ranked as the least prevalent. Therefore, poor attention and motivation was dropped from the final definition of hypotonia syndrome.
The process of developing the diagnostic label of hypotonia syndrome was relatively simple and one that any PT could replicate. The initial survey asked open-ended questions based upon the first author's (K.M.) clinical experience of common deficits in children with hypotonia.11 The coding of responses into 8 major categories was in itself a microcosm of the diagnosis process in that it represented grouping of terms, or pattern recognition, in the responses. The second survey was more closed-ended and required simple descriptive statistics (percentage, means) to analyze the responses.12 The strength of this process to identify the diagnosis of hypotonia syndrome was that it used random sampling of relevant professionals, was interdisciplinary, and operationally defined when consensus had been reached. The strength of the hypotonia syndrome diagnosis is that only the characteristics that evolved from consensus were included. This diagnosis is grounded in the human movement system and leads to the choice of appropriate intervention strategies, such as activities to promote strengthening, endurance, acquisition of motor abilities and skills, and improved posture.
One limitation of the diagnosis of this syndrome is that the label of hypotonia syndrome represents only 1 of the impairments captured by 7 characteristics. Perhaps the label needs to be modified to more accurately describe this human movement system syndrome. Another limitation is that the signs and symptoms are not linked to diagnostically specific tests and measures. In fact, approximately 75% of respondents in both surveys noted that they were unaware of an objective measure for hypotonia, or that they used observation of posture and movement to document the disorder. Thus, at this point in time, this syndrome label fails to fully satisfy the definition of a diagnosis given by Sahrmann in that it is not based on the information gained from “tests the therapist performs or requests.”1(p1705) In addition, prognosis and age-related differences have yet to be addressed in the diagnosis as currently defined; however, 85.4% of the respondents from the first survey indicated that children with hypotonia do improve with therapy.11
The diagnosis of this human movement syndrome would be improved with further research to better describe and quantify the 7 identified characteristics. In other words, how weak (hypermobile, delayed, etc) does a child have to be in order to be given the diagnosis of hypotonia syndrome? This work may lead to an improved and more representative label for this syndrome and ultimately improved intervention strategies.
Developmental Coordination Disorder Syndromes
Developmental coordination disorder (DCD) is a human movement system diagnosis that, different from hypotonia syndrome, has been studied to a great extent and reported within the literature (Appendix 3). Through literature searches, one can find information that defines DCD, describes appropriate tests and measures to determine the DCD diagnosis, and begins to define additional subtype syndromes within the broad DCD diagnosis. The following information summarizes a literature review for articles published within the last 25 years using search terms of DCD and diagnosis, assessment, tests, measures, and physical therapy intervention. For an extensive list of references, readers are referred to the recent recommendations on the definition, diagnosis, and intervention for children with DCD approved at 2 consensus conferences in Europe,13 a meta-analysis summarizing the literature over the last 14 years in relationship to the motor control and cognitive deficits associated with DCD14 and a systematic review and meta-analysis of the efficacy of interventions for children with DCD.15
The American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 4th edition,16 defines DCD as encompassing the following 4 components: (A) motor coordination in activities substantially below expectations for age and intelligence; (B) interferes with academic achievement or activities of daily living; (C) not due to a general medical condition; and (D) if intellectual delay, motor difficulties are greater than would be expected. This definition was created in 1987 to be used for children presenting with poor motor coordination and replaced past terms such as “clumsy child,” “minimal brain damage,” and “developmental dyspraxia.” For each component of the diagnosis, specific tests and measures common to pediatric physical and occupational therapy are recommended to make the diagnosis. For criterion A, the Movement Assessment Battery for Children, 2nd edition, is the most widely used test to diagnose DCD17–19; however, there is some criticism due to poorly documented reliability and validity.17 The Bruininks Oseretsky Test–2nd edition also can be used and provides a more detailed examination of gross and fine motor ability.20,21 Others have used more extensive tests and measures.22–25 For criterion B, there are a number of semistructured interview/questionnaires related to effects of coordination difficulties on self-care, school activities, etc. These include, for example, the M-ABC parent/teacher checklist26 and the DCD questionnaire (DCD-Q).27–30 For criterion C, therapists are recommended to refer to a medical doctor to rule out genetic, metabolic, traumatic brain damage, degenerative condition, and pervasive developmental disorder, which would exclude the child from a DCD diagnosis.31 Several other secondary diagnoses such as attention-deficit disorder and attention-deficit/hyperactivity disorder occur quite frequently with DCD,13,31 with some researchers indicating that this negates a pure DCD diagnosis and others seeing it as a potential component of DCD.32,33 For criterion D, PTs with the appropriate training can give screening tests such as the Kaufman Brief Intelligence Test, 2nd edition,34 to understand intellectual ability, but should rely on educational or psychological professionals for definitive tests of intellectual ability. Given that the collaboration of PTs, physicians, and psychologists is currently necessary, the diagnosis is often not made until the child enters school programs, where such teams exist.
Although the DCD diagnosis is clearly defined, it captures a large variety of children who have variable clinical signs and symptoms and thus it has been suggested that there are more specific subtypes or syndromes within this broad diagnosis, which need to be identified to better direct the most appropriate interventions. These more refined diagnostic groups have been determined through both clinical testing and reasoning as well as through complex statistical procedures including factor analysis and cluster analysis.32,35–38 Dependent on the tests and measures used prior to the specific syndrome determination, various classification systems have been devised, but there is no overall concurrence on any specific set of subtype classifications.
These more refined syndromes within the broad DCD classification have been proposed on the basis of the following: (1) type or quality of motor impairment, for example, weak kinesthesia, poor static balance, weak static and dynamic balance, poor fine motor and perceptual, motor planning and programming deficit, visual/spatial motor impairment, and mixed32,36,39; (2) behavioral, social, emotional problems, for example, codiagnoses of DCD-attention-deficit disorder, DCD-attention-deficit/hyperactivity disorder, DCD-specific language impairment, DCD-learning disability, and DCD-pervasive developmental disorder40; (3) severity of coordination deficit, for example, borderline, definite, severe32; and (4) etiology/history, for example, premature delivery.41,42
Greater specificity of testing for children determined to have the general diagnosis of DCD should eventually lead to more precise identification of specific human movement syndromes falling under the umbrella term DCD, which PTs can unilaterally identify. Continued research in this area is warranted.
Many types of physical and occupational therapy programs have support in the literature for improving motor ability in children with DCD. For example, the use of Cognitive-Orientation to Daily Occupational Performance intervention allows the child to select an age-relevant functional goal. The therapist then selects and organizes environmental factors to fit the child's level of competency, giving verbal prompts (goal, plan, do, check) to encourage reflection and planning.43–45 Specific motor imagery training includes observation of skilled models on videos, then creating an action replay by imagining one's self doing the activity. After the child completes mental practice, then they complete physical practice.46–48 Task-specific practice following motor learning parameters also has support in the literature, including careful use of feedback and practice to promote skilled motor behaviors.49–52 Sensory-based practice to influence better use of sensory systems (vestibular, visual, kinesthetic) within motor and postural control have been employed.13,53,54 Overall, on the basis of these recommended therapies, the prognosis of children with DCD is positive.
In summary, clear documentation related to assigning a DCD diagnosis exists, and PTs are among the primary health care professionals who have the appropriate background and training to make the diagnosis. In addition, this diagnosis does help identify examination and intervention strategies. The limitation of this broad diagnosis, however, is that it needs further refinement into more specific movement syndromes that could potentially then lead the therapist to the most effective and efficient interventions. Some initial research related to identifying subtype movement syndromes has been done; however, to date, agreement has not been reached on specific syndromes, and age-related differences have not been addressed. More research is needed.
Pediatric Obesity Syndrome
Nearly one third of US children aged 2 to 19 years meet criteria for overweight or obesity (≥85th body mass index [BMI] percentile).55 In addition to medical complications such as dyslipidemia, hypertension, and type 2 diabetes,56 pediatric obesity has been linked with functional deficits in gait,57,58 balance,57,59 cardiopulmonary fitness relative to body mass,60,61 relative lower extremity strength,62 and motor abilities.63 Because PTs are movement specialists, they can play a key role in pediatric obesity prevention and treatment by addressing an individual's weight-related functioning and disability, as well as promoting contextual factors to help enhance movement and decrease sedentary behaviors. However, physical therapy management for pediatric obesity, particularly the effect of obesity on functional activity limitations, has been relatively underrecognized and understudied. Identifying key areas of functional movement affected by obesity could serve to frame a diagnosis and help guide physical therapy management of this condition. Thus, the initial step in developing a diagnosis began by conducting a systematic literature review to develop a list of functional movement conditions that have been identified in children with obesity.
A comprehensive search of MEDLINE, CINAHL, and PEDro (articles published January 2000 through August 2010) was conducted using single and multiple key word terms of overweight, obesity, children, adolescents, movement, and musculoskeletal. Articles were included if the study identified dysfunction(s) that were judged to be within the scope of PT practice that affect the functional movement system in pediatric populations (birth-20 yrs) described as having a condition of overweight, obesity, or both. Searches were limited to English-language articles reporting both nonexperimental and experimental research studies. The database searches resulted in 2413 articles. Following detailed abstract review, and full-article evaluation when necessary, a total of 34 articles were included in the review.
Based on the literature review, 7 clinical characteristics of overweight/obesity related to the functional movement system were identified: (1) aerobic fitness deficit/deconditioning64; (2) lower extremity orthopedic malalignment65,66; (3) gait dysfunction67–70; (4) lower extremity functional muscle strength deficit71; (5) motor control deficit/movement incoordination63,72–74; (6) pain75,76; and (7) proprioception deficit.77,78 A brief description of clinical problems associated with each characteristic follows.
Aerobic fitness deficit/deconditioning was a common finding among children and adolescents with overweight/obesity. Performance on various measures of aerobic fitness such as walk/run tests is poorer in children with overweight/obesity than in lean peers.64
Lower extremity orthopedic malalignment that affects movement in children with overweight/obesity includes slipped capital femoral epiphysis, genu valga, tibia vara (Blount's disease), and pes planus.65,66
Gait dysfunction includes slower self-selected speed, wider and shorter steps, increased double-limb support time during walking,67,68 differences in joint kinematics during walking such as collapse of proximal stance limb (hip adduction, knee valgus) with distal compensation (rear foot inversion),69 and increased absolute peak joint moments at the hip, knee, and ankle.70
Lower extremity functional muscle strength deficit may be decreased in youth with overweight and obesity for gravity-dependent tasks such as vertical leap and standing long jump.71
Motor control deficit/movement incoordination may be associated with higher BMI and overweight/obesity based on cross-sectional research.63,72–74
Pain (back/foot/knee) has been reported in children with overweight and obesity with back pain most commonly reported.75,76
Proprioception deficit has been suggested to be a concern for children with obesity, particularly poorer kinesthetic proprioception in knee flexion that may be associated with decreased postural control.77,78
After the clinical characteristics of overweight and obesity affecting functional movement were identified, an online survey was developed to assess pediatric PTs' agreement, rank order and clinical effect, and opinions on the clinical characteristics. The link to the online survey was e-mailed to APTA members of the Section on Pediatrics and was also made available through a posting on the Section's Web site. Participants were asked to complete the survey only if they were a practicing PT who regularly treated pediatric patients. Participants were asked to consider pediatric patients that they treat to be overweight or obese if they resembled a silhouette of children representing overweight/obesity in a provided illustration of a series of body types.79 Procedures for survey data collection received the full Institutional Review Board approval prior to implementation.
A total of 75 pediatric PTs completed the survey. Level of agreement with the 7 clinical characteristics of overweight/obesity was assessed with a 5-point Likert scale ranging from strongly agree to strongly disagree. Percentage of respondents who replied strongly agree or agree for each clinical characteristic was as follows: (1) aerobic fitness deficit/deconditioning (100%); (2) lower extremity orthopedic malalignment (84%); (3) gait dysfunction (80%); (4) lower extremity functional muscle strength deficit (75%); (5) motor control deficit/movement incoordination (64%); (6) pain (49%); and (7) proprioception deficit (37%).
When the clinical characteristics were ranked on the basis of how commonly observed they were in patients who are overweight/obese, the order was aerobic fitness deficit/deconditioning ranked first followed by lower extremity orthopedic malalignment, lower extremity functional muscle strength deficit, gait dysfunction, motor control deficit/movement incoordination, pain, and proprioception deficit.
The clinical characteristics were also ranked in order of effect on the functional movement system with the following rank order: lower extremity functional muscle strength deficit, lower extremity orthopedic malalignment, aerobic fitness deficit/deconditioning, motor control deficit/movement incoordination, gait dysfunction, pain, and proprioception deficit.
Overall the results of the survey indicated that the majority of participants strongly agreed or agreed that the following 5 signs/symptoms best represent the human movement characteristics of pediatric patients who are overweight or obese: (1) aerobic fitness deficit/deconditioning, (2) lower extremity orthopedic malalignment, (3) gait dysfunction, (4) lower extremity functional muscle strength deficit, and (5) motor control deficit/movement incoordination. Based on the majority agreement, pediatric obesity syndrome was defined as “A human movement system dysfunction associated with excess adiposity that is characterized by aerobic fitness deficit/deconditioning, lower extremity orthopedic malalignment and strength deficit, gait dysfunction, and motor control deficit” (Appendix 4).
Because the diagnosis of pediatric obesity syndrome is based on signs and symptoms of human movement dysfunction that help guide intervention, and because there is a lack of universal consensus on a weight-for-height criterion to define overweight/obesity in children, a specific BMI value is not identified in the definition of the syndrome. Furthermore, BMI is most appropriate as a screening and health surveillance tool rather than a diagnostic measure.80 Further research is needed to determine which BMI cutoffs for children are associated with increased health risk, functional decline, and that account for personal factors such as age, race, sex, and family history.80,81 However, the phrase “associated with excess adiposity” was included as part of the syndrome definition to clarify that this syndrome is specific to children who generally would be screened as having a higher BMI (and a physician's diagnosis) that classifies them as having overweight or obesity, and to children who are at greater health risk. This definition provides a testable diagnostic classification of pediatric obesity that was developed on the basis of a systematic review and survey of experienced and geographically diverse pediatric PTs. However, further assessment of the definition is needed since it was developed on the basis of results of a relatively small sample of studies, with some that only examined boys, and is based on self-perceptions that need to be tested using objective functional measures. Nevertheless, this definition of pediatric obesity syndrome provides a beginning point to help guide assessment and intervention for children who are overweight and obese. Future research is needed to assess the validity of this diagnosis of pediatric obesity along with evidence-based strategies for prevention and treatment.
None of the 3 diagnoses presented entirely fulfill the vision of the Diagnosis Dialog group. Although all 3 are evidence-based, focused on the human movement system and help guide intervention, they each have their limitations as previously identified. The hypotonia and obesity syndromes may not have the ideal “label” in that a body structure characteristic serves as the syndrome name, rather than a term that reflects the human movement disorder. The DCD syndrome needs more refinement of the subtypes to more effectively guide intervention. None of the proposed diagnoses really address prognosis. Further discussion, validation, and consensus on these 3 examples are needed before they can be promoted for wider use. This will require, in part, using the proposed diagnoses in clinical settings to help with examination and to guide intervention. Reaching consensus on the components that comprise diagnostic syndromes will provide a standardized terminology and guide for clinical practice.
Proposed syndrome definitions need to be developed for other conditions as well. An online template is provided so that colleagues can begin this process and post their ideas for public discussion.82 We believe that online forums of subcommittees for developing other syndromes along with case scenarios to illustrate their clinical applications would be one potential method for helping advance the work in this area.
CONCLUSION AND LESSONS LEARNED ABOUT PEDIATRIC DIAGNOSES
The Diagnosis Dialog group has clearly articulated not only that diagnosis is within the scope of practice of PTs, but also that it is also imperative that we embrace it if we are to continue to build a scientific basis for our practice.7 The task of defining human movement system syndromes commonly seen in children is not as daunting as it seems and it requires us to document what we already do: pattern recognition and categorization of signs and symptoms of human movement dysfunction that guide intervention. There are many viable approaches to achieve this end, and this article has provided several examples that can readily be implemented in a clinical setting. These examples included reviewing the literature and the use of surveys to identify consensus. The Diagnosis Dialog group has noted that obtaining unanimity on diagnostic labels is challenging and perhaps not even possible in a profession as diverse as PT. However, although we may not agree on everything, we should be able to agree on some things—we challenge our colleagues to start with those points of agreement.
We thank Ann Van Sant for her vision in bringing this topic to the Section on Pediatrics in the first place and for her consistently sage advice to the Diagnosis Task Force throughout our work. This work would not have gotten done without her guidance. We also thank Barbara Norton of Washington University for her determination to spread the work of the Diagnosis Dialog group to other specialty areas, and for her invitation for us to be a part of the Diagnosis Dialog conversations. Finally, we acknowledge the vision of the 2009 Section on Pediatrics' Board of Directors for writing this important task into the section's strategic plan, thus showing their commitment to this concept and process.
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44. Hyland M, Polatajko HJ. Enabling children with developmental coordination disorder
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45. Polatajko HJ, Mandich AD, Miller LT, Macnab JJ. Cognitive orientation to daily occupational performance (CO-OP): part II—the evidence. Phys Occup Ther Pediatr. 2001;20:83–106.
46. Wilson PH, Thomas PR, Maruff P. Motor imagery training ameliorates motor clumsiness in children. J Child
47. Williams J, Anderson V, Reddihough DS, Reid SM, Vijayakumar N, Wilson PH. A comparison of motor imagery performance in children with spastic hemiplegia and developmental coordination disorder
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48. Williams J, Thomas PR, Maruff P, Wilson PH. The link between motor impairment level and motor imagery ability in children with developmental coordination disorder
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49. Schoemaker MM, Niemeijer AS, Reynders K, Smits-Engelsman BC. Effectiveness of neuromotor task training for children with developmental coordination disorder
: a pilot study. Neural Plast. 2003;10:155–163.
50. Pless M, Carlsson M, Sundelin C, Persson K. Effects of group motor skill intervention on five- to six-year-old children with developmental coordination disorder
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51. Pless M, Carlsson M, Sundelin C, Persson K. Pre–school children with developmental co-ordination disorder: self-perceived competence and group motor skill intervention. Acta Paediatr. 2001;90:532–538.
52. Dunford C. Goal-orientated group intervention for children with developmental coordination disorder
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53. Fong SS, Tsang WW, Ng GY. Taekwondo training improves sensory organization and balance control in children with developmental coordination disorder
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54. Fong SS, Lee VY, Pang MY. Sensory organization of balance control in children with developmental coordination disorder
. Res Dev Disabil. 2011;32:2376–2382.
55. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity
and trends in body mass index among US children and adolescents, 1999-2010. JAMA. 2012;307:483–490.
56. Goran MI, Ball F, Cruz M. Obesity
and risk of type 2 diabetes and cardiovascular disease in children and adolescents. J Clin Epidemiol Metab. 2003;88:1417–1427.
57. Colne P, Frelut ML, Peres G, Thoumie P. Postural control in obese adolescents assessed by limits of stability and gait initiation. Gait Posture. 2008;28:164–169.
58. Nantel J, Brochu M, Prince F. Locomotor strategies in obese and non-obese children. Obesity
59. McGraw B, McClenaghan BA, Williams HG, Dickerson J, Ward DS. Gait and postural stability in obese and nonobese prepubertal boys. Arch Phys Med Rehabil. 2000;81:484–489.
60. Grund A, Dilba B, Forberger K, Krause H, Siewers M, Rieckert H, Muller MJ. Relationships between physical activity, physical fitness, muscle strength and nutritional state in 5- to 11-year-old children. Eur J Appl Physiol. 2000;82:425–438.
61. Rump P, Verstappen F, Gerver WJM, Hornstra G. Body composition and cardiorespiratory fitness indicators in prepubescent boys and girls. Int J Sports Med. 2002;23:50–54.
62. Blimkie CJ, Sale DG, Bar-Or O. Voluntary strength, evoked twitch contractile properties and motor unit activation of knee extensors in obese and non-obese adolescent males. Eur J Appl Physiol Occup Physiol. 1990;61:313–318.
63. Graf C, Koch B, Kretschmann-Kandel E, et al. Correlation between BMI, leisure habits and motor abilities in childhood (CHILT-project). Int J Obes Relat Metab Disord. 2004;28:22–26.
64. Drinkard B, McDuffie J, McCann S, Uwaifo GI, Nicholson J, Yanovski JA. Relationships between walk/run performance and cardiorespiratory fitness in adolescents who are overweight
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65. Wills M. Orthopedic complications of childhood obesity
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66. Mauch M, Grau S, Krauss I, Maiwald C, Horstmann T. Foot morphology of normal, underweight and overweight
children. Intern J Obes. 2008;32:1068–1075.
67. Hills AP, Parker AW. Gait characteristics of obese children. Arch Phys Med Rehabil. 1991;72:403–407.
68. Hills AP, Parker AW. Locomotor characteristics of obese children. Child
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69. McMillan AG, Pulver AME, Williams BDS. Sagittal and frontal plane mechanics throughout the stance phase of walking in adolescents who are obese. Gait Posture. 2010;32:263–268.
70. Shultz SP, Sitler MR, Tierney RT, Hillstrom HJ, Song J. Effects of pediatric obesity
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74. Cliff DP, Okely AD, Morgan PJ, Jones RA, Steele JR, Baur LA. Proficiency deficiency: mastery of fundamental movement skills and skill components in overweight
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75. Taylor ED, Theim KR, Mirsh MC, et al. Orthopedic complications of overweight
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76. Stovitz SD, Pardee PE, Vazquez G, Duval S, Schwimmer JB. Musculoskeletal pain in obese children and adolescents. Acta Paediatr. 2008;97:489–493.
77. Wang L, Li JX, Xu DQ, Hong YL. Proprioception of ankle and knee joints in obese boys and nonobese boys. Med Sci Monit. 2008;14:CR129–CR135.
78. Deforche BI, Hills AP, Worringham CJ, et al. Balance and postural skills in normal-weight and overweight
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80. Flegal KM, Ogden CL. Childhood obesity
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81. Epstein LH, Wrotniak BH. Future directions for pediatric obesity
Template for Development of Diagnoses81
- Brief overview: Provide a brief overview of the prototypical patient for whom the movement system diagnosis you will describe would be appropriate.
- General demographics: State the age range of individuals commonly affected.
- General demographics: Indicate the sex of individuals commonly affected.
- General demographics: List other key demographic characteristics of individuals commonly affected (eg, race/ethnicity, primary language, etc).
- History of current condition: List key data from the history of a typical patient that are related to the movement system condition (eg, patient concerns, mechanism of injury or disease, onset and pattern of symptoms, expectations and goals).
- General history: List other key data, if any, from the history of a typical patient that are specifically relevant to the movement system condition in individuals commonly affected (eg, medications, other tests and measures, history of current condition, previous hospitalizations and surgeries, preexisting health-related conditions, social history, occupation, growth and development, living environment, family history, social habits).
- Tests and measurements: List key tests that should be performed and results expected for individuals commonly affected; if relevant, key negative tests should be included.
- Activity and participation: List key activity limitations and participation restrictions that typically are evident in individuals with the condition.
- Key elements missing: If there are any other characteristics that are key elements of this movement system diagnosis and you have not yet had the opportunity to describe them, please list them.
- Diagnoses to rule out: List other conditions with similar presentation that would need to be “ruled out.”
- Diagnosis: What is the proposed name of the human movement system condition?
- Rationale for name of diagnosis: What is the basis for the name used to identify the movement system condition (eg, anatomic, physiologic, kinesiologic, response to movement, response to treatment)?
- Supporting evidence: If the movement system condition that you have described has been reported previously in the literature, please cite reference(s).
- Contributor information: What is your name?
- Contributor information: In which state are you located?
- Contributor information: In what type of facility do you work?
- Contributor information: What is your primary area of practice?
- Contributor information: Are you an American Board of Physical Therapy Specialties (ABPTS)-certified specialist?
- Contributor information: What is your specialty area?
- Contributor Information: How many years have you been a physical therapist?
- Survey feedback: If the structure provided by the questions in this survey did not allow you to describe the condition adequately, what additional question(s) need to be included?
- Survey feedback: Please use this space to provide additional suggestions or comments. Thank you for your contribution!
- Brief overview: Children with gross motor delays, may or may not have a medical diagnosis.
- General demographics (age range): Hypotonia can be present throughout the lifespan; however, children aged birth to 5 years are most likely to be referred to physical therapy for concerns about delayed acquisition of motor milestones.a-c
- General demographics (gender): Both male and female; no statistics available on which gender is more affected.
- General demographics (other): No known data on ethnicity or race
- History of current condition: Delay in meeting gross motor milestones,a,c,d particularly related to postural control (head control, independent sitting). Age of onset is typically at birth,a,c,e,f although delays may not become apparent for several months. May or may not be history of similar concerns with other family members. Contradictory reports indicate that hypotonia may persist throughout life with associated “clumsiness,”a while others note gradual improvement with age.b,d,e One author noted that children with congenital hypotonia are later identified adolescents with joint hypermobility,e although no other study has confirmed this.
- Characteristics identified in consensus survey: Decreased strength, joint hypermobility, increased flexibility/muscle extensibility, delayed motor abilities or skills, leaning on supports, decreased activity tolerance, and rounded shoulder posture.g,h
- General history: No specific prenatal, perinatal, or postnatal history. May have history of poor feedinga (failure to thrive, lengthy feedings, aspiration risk), frequent upper respiratory tract infections compared to typical infants.
- Tests and measurements: Any standardized developmental assessment tool that is norm-referenced and appropriate for the age and developmental status of the child. Gross motor delays likely more than 1.5 standard deviations from mean for age.
- Differential diagnosis by physician might involve blood and urine studies, magnetic resonance imaging or computed tomographic scan, and muscle biopsy to rule out metabolic and mitochondrial disorders, genetic syndromes, central nervous system disorders, and progressive muscle diseases.a,c,f,i
- Activity and participation: Depending on severity, lead to lack of independent mobility (rolling, creeping, cruising, walking, etc). This may delay or inhibit independent exploration of environment, which could impair development in other areas (cognitive, social-emotional, fine motor, language, adaptive, and self-help). Children with hypotonia tend to eventually achieve independent mobility over time but often cannot keep up with peers developing typically.j This may limit social and play opportunities at home, in school, and in the community.
- Key elements missing: Cognition may or may not be affected.
- Diagnoses to rule out: Hypotonic cerebral palsy, spinal muscular atrophy, genetic syndromes, metabolic or mitochondrial disorders, muscular dystrophy, congenital central nervous system malformations (including myelodysplasia).a,c,f
- Diagnosis: Hypotonia syndrome is a human movement system syndrome characterized by decreased strength, increased flexibility/muscle extensibility, hypermobility, decreased activity tolerance, delayed motor abilities or skills, leaning on supports and rounded shoulder posture.
- Rationale for name of diagnosis: Physiologic
- Crawford TO. Clinical evaluation of the floppy infant. Pediatr Ann. 1992;21:348-352.
- Shuper A, Weitz R, Varsano I, Mimouni M. Benign congenital hypotonia: a clinical study of 43 children. Eur J Pediatr. 1987;146:360-362.
- Lisi EC, Cohn RD. Genetic evaluation of the pediatric patient with hypotonia: perspective from a hypotonia specialty clinic and review of the literature. Dev Med Child Neurol. 2011;53:586-599.
- Bodensteiner JB. Hypotonia, congenital hearing loss and hypoactive labyrinths. J Child Neurol. 2003;18:171-173.
- Carboni P, Pisani F, Crescenzi A, Villani C. Congenital hypotonia with favorable outcome. Pediatr Neurol. 2002;26:383-386.
- Prasad AN, Prasad C. The floppy infant: contribution of genetic and metabolic disorders. Brain Dev. 2003;25:457-476.
- Martin K, Inman J, Kirschner A, Deming K, Gumbel R, Voelker L. Characteristics of hypotonia in children: a consensus opinion of pediatric physical and occupational therapists. Pediatr Phys Ther. 2005;17:275-282.
- Martin K, Kaltenmark T, Lewallen A, Smith C, Yoshida A. Clinical characteristics of hypotonia: a survey of pediatric physical and occupational therapists. Pediatr Phys Ther. 2007;19:217-226.
- Paro-Panjan D, Neubauer D. Congenital hypotonia: is there an algorithm? J Child Neurol. 2004;19:439-442.
- Jacobson RD. Approach to the child with weakness or clumsiness. Pediatr Clin N Am. 1998;45:145-168.
Developmental Coordination Disorder
- Children's motor milestones (eg, sitting, crawling, walking) may not be delayed, but the development of motor skills and learned movements will be delayed even though there have been adequate opportunities to learn.a
- Children's behavioral, social, or emotional health is affected.
- Impairments in motor coordination are not solely explicable due to general intellectual disability or any specific congenital or acquired neurological disorder and significantly interfere with academic achievement and activities of daily living.b,c
- Severity of presentations varies.
- Potential subclassifications of children with DCD due to problems with fine motor/perception, postural control, kinesthesia, or all.c,d
General demographics (age range)
- Usually diagnosed between age 5 and 16 years, but repeated testing (at least 3 months apart) in 3- to 5-year-olds can lead to the diagnosisb
- Diagnosis after the age of 16 years needs to be considered on the basis of adult criteria
General demographics (gender): Both male and female, but greater number of males, varying from 2:1 to 7:12. One study suggests a more equal number of males to females 1.2:1e
General demographics (other): Occurs across cultures, races, and socioeconomic conditionsb
History of current condition
- May or may not have mildly delayed motor milestone developmenta,b
- Will have motor skill development delay; may have deficits in fine motor skills, balance, catching, and reaching, and as task/environmental demands increase coordination decreasesa,b
- May have underlying problems in visual-motor translation (namely inverse modeling) for movements directed within and outside peripersonal space, adaptive postural control, and the use of predictive control (namely forward modeling), which affects the ability to adjust movement to changing constraints in real timeb,c
- May have specific dysfunction in proprioception, processing of kinesthetic information, processing sensory information for postural control (static and dynamic), processing efferent (feed forward) information, motor imagery, speed of movements, visual memory, language processingb,c
- May have decreased strength and fitnessb
Reported by parent or teacher to:
- Move awkwardly; seem clumsy and trip frequently; have trouble with writing, cutting, handling utensils, tying shoelaces, etc; avoid participation in physical or motor-based activities; have difficulty learning or transferring new motor skills; have behavioral problems or “not work hard enough” to complete motor tasksa,f
- High probability of codiagnoses of attention-deficit/hyperactivity disorder (ADHD), specific language impairment, specific learning disabilities, developmental dyslexia or reading disability, or autistic spectrum disorder (ASD)a-f
- May or may not be on medications for ADHD, ASD
- May be associated with prematurity without overt central nervous system involvementb
Tests and measurements
Multidisciplinary assessment recommendedb,g
- DCD Questionnaire- Revised (DCD-Q-R)
- Movement Assessment Battery for Children, 2nd Ed Checklist (M-ABC2 checklist)
- Movement Assessment battery for Children, 2nd Ed (M-ABC2) (recommended that 15th percentile or standard score of 7 or less be used as the cutoff; 5th percentile for FM)
- Bruininks-Oseretsky Test of Motor Impairment (BOT-2) (recommended that 15th percentile as cutoff overall, 5th percentile for FM)
- Canadian occupational performance measure
- Perceived Efficacy Goal Setting & Goal Attainment Scaling
- Children's Assessment of Participation and Enjoyment and the Preferences for Activities of Children (CAPE-PAC)
- Peabody Developmental Motor Scales
- Various handwriting tests, appropriate for the culture (ex. Minnesota Handwriting Test, Diagnosis and Remediation of Handwriting Problems, etc)
- Various gait assessments (ex. GaitRite, Timed walk or run tests)
- Gait and ball skills (Test of Gross Motor Development, 2nd ed)
- Canadian Occupational Performance Measure
- Perceived Efficacy Goal Setting and Goal Attainment Scaling
Body structure/function testing
- Visual-motor tests
- Developmental Test of Visual Perception, 2nd ed
- Movement Coordination Tests (Ex. finger to nose; Clinical Observations of Motor and Postural Skillsg)
- Postural control testsi
- Sensory interaction
- Pediatric Clinical Test of Sensory Interaction for Balance (P-CTSIB)
- Sensory Organization Test
- Dynamic Gait Indexj
- Motor activation
- Reactive postural adjustments
- Perturbation of body or surface (Ex. push/pull test, one foot balance)
- Anticipatory postural adjustments (Ex. Functional Reach Test)
- Type, timing, and adaptability of motor strategy used in static and dynamic balance (ankle, hip, stepping, reach/grasping, crouching)
- Strength tests (use of hand-held dynamometry for appropriate muscle groups)
Activity and participation
- Fine motor skills (handwriting, shoe tying, buttoning, zippering, etc)
- Ball skills (throwing, catching, hitting, kicking)
- Completion of complex movements (ex. jumping jacks, skipping, etc)
- Participation in age-appropriate games and sports (ex. hop-scotch, tumbling, baseball, soccer, basketball, etc)
- Participation in academic achievement
- Participation in activities of daily living
Key elements missing: Incidence rate: 5%-20% with 5%-6% being most frequently quotedb
Diagnoses to rule out:
- Neurological disorders such as of corticospinal, cerebellar, extrapyramidal, or neuromuscular origina-d
- Genetic syndromes
- Deprivation of adequate opportunities for learning motor skills within social and community environment
- Behavioral disorders
- Cognitive dysfunction
- Minor neurological dysfunction or neurological soft signs (eg, associated movements, mirror movements)
- Obesity, fitness disorders
- Primary end-organ sensory disorders (vision, vestibular, cutaneous)
Diagnosis: developmental coordination disorder
Rationale for name of diagnosis: Kinesiologic
- Early Indicators of DCD. http://dcd.canchild.ca/en/AboutDCD/earlyindicators.asp. Accessed February 4, 2012.
- Blank R, Smits-Engelsman B, Polatajko H, Wilson P. European Academy for Childhood Disability (EACD): recommendations on the definition, diagnosis and intervention for developmental coordination disorder (long version). Dev Med Child Neurol. 2012;54(1):54-93.
- Wilson PH, Ruddock S, Smits-Engelsman B, Polatajko H, Blank R. Understanding performance deficits in developmental coordination disorder: a meta-analysis of recent research [published online ahead of print October 29, 2012]. Dev Med Child Neurol. doi:10.1111/j.1469-8749.2012.04436.x.
- Green D, Chambers ME, Sugden DA. Does subtype of developmental coordination disorder count: is there a differential effect on outcome following intervention? Hum Mov Sci. 2008;27(2):363-382.
- Cairney J, Veldhuizen S, Kurdyak P, Missiuna C, Faught BE, Hay J. Evaluating the CSAPPA subscales as potential screening instruments for developmental coordination disorder. Arch Dis Child. 2007;92(11):987-991.
- Missiuna C, Gaines R, McLean J, Delaat D, Egan M, Soucie H. Description of children identified by physicians as having developmental coordination disorder. Dev Med Child Neurol. 2008;50:839-844.
- Watter P, Rodger S, Marinac J, Woodyatt G, Ziviani J, Ozanne A. Multidisciplinary assessment of children with developmental coordination disorder: using the ICF framework to inform assessment. Phys Occup Ther Pediatr. 2008;28(4):331-352.
- Wilson B, Pollock N, Kaplan BJ, Law M, Faris P. Reliability and construct validity of the Clinical Observations of Motor and Postural Skills. Am J Occup Ther. 1992;46(9):775-783.
- McCoy S, Liu W, Kartin D. Evaluation and Intervention for Postural Control Disorders in Children, 2nd ed. LMS-222. American Physical Therapy Association Leaning Center Website.http://learningcenter.apta.org/shared/courseDescription.aspx? Course ID = 861&clientID = 501&URL = http://learningcenter.apta.org
- Lubetzky-Vilnai A, Jirikowic T, Westcott McCoy S. Investigation of the Dynamic Gait Index in children with and without postural control dysfunction: a pilot study. Pediatr Phys Ther. 2011;23(3):258-266.
Pediatric Obesity Syndrome
- Brief overview: Children and adolescents who meet criteria for overweight or obesity (eg, Centers for Disease Control and Prevention's 2000 growth charts: overweight: body mass index-for-age at or above the sex-specific 85th percentile but less than the 95th percentile, obesity: body mass index-for-age at or above the sex-specific 95th percentilea)
- General demographics (age range): Infants aged 0 to 2 years and children/adolescents aged 2 to 19 years. This template report is based on children and adolescents.
- General demographics (gender): Both males and females. Obesity prevalence for males (18.6%) is significantly higher than that for females (15.0%). Obesity rates significantly differ by gender for non-Hispanic white children and adolescents (obesity in males: 16.1%; females: 11.7%). No differences by gender for Hispanic or non-Hispanic black children and adolescents.b
- General demographics (other): Among children and adolescents aged 2-19 years, 16.9% were obese in 2009-2010 and 31.8% were either overweight or obese. Highest prevalence is among non-Hispanic black (obese: 24.3%; overweight or obese: 39.1%), Mexican American black (obese: 21.2%; overweight or obese: 39.4%), and Hispanic black (obese: 21.2%; overweight or obese: 39.1%) children and adolescents.b
- History of current condition: Family history of obesity is a strong predictor of pediatric obesity (generally highest odds for youth with obesity in both parents, then mother, then father, and then siblings).c Growth patterns (early rapid growthd and early adiposity rebounde) may be an early marker of obesity. May have history of skipping breakfast, frequent eating out, physical inactivity, and increased television/media viewing.f Food insecurity and activity- and eating-related built neighborhood characteristics may be related to obesity.g
- Characteristics identified in consensus survey: Aerobic fitness deficit/deconditioning, lower extremity orthopedic malalignment, gait dysfunction, lower extremity functional muscle strength deficit, and motor control deficit/movement incoordination
- General history: May report difficulty or pain (back/foot/knee) with physical activitiesh; sleep problems (asthma, sleep apnea)i; health conditions, including cardiovascular and gastrointestinal disorders; diagnosed depression; and eating disorders.j
- Tests and measurements: Measurement of height and weight to compute body mass index percentile; waist-to-hip ratio; walk/run test; lower extremity strength; orthopedic assessment; physical activity; sedentary behaviors; motor skills; readiness/motivation/confidence for making health behavior change; social support. Signs may include acanthosis nigricans, slipped capital femoral epiphysis, pes planus, and Blount's disease.k,l
- Activity and participation: Activity limitations may include slower self-selected speed, wider and shorter steps, and increased double-limb support time during walking.m,n Limitations may also be seen in coordination and dynamic balance/postural control activities, walking distance endurance, running, leaping, jumping, rising from a chair or seated position.o-q Potential participation restrictions may be related to psychosocial health and include decreased participation in organized sport activities.r
- Differential diagnosis: Physician examination may investigate comorbid conditions associated with obesity in children: thyroid disorders, Cushing's, Prader-Willi syndrome, type 2 diabetes, and hepatomegaly.
- Diagnosis: Pediatric obesity syndrome: A human movement system dysfunction characterized by aerobic fitness deficit/deconditioning, lower extremity orthopedic malalignment and strength deficit, gait dysfunction, and motor control deficit associated with excess adiposity.
- Rationale for name of diagnosis: Current medical classification of overweight and obesity identifies criteria for classifying a child's weight status but does not indicate the clinical characteristics affecting functional movement.
- Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: methods and development. Vital Health Stat 11. 2002;246:1-190.
- Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA. 2012;307:483-490.
- Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337:869-873.
- Dennison BA, Edmunds LS, Stratton HH, Pruzek RM. Rapid infant weight gain predicts childhood overweight. Obesity. 2006;14:491-499.
- Williams SM, Goulding A. Early adiposity rebound is an important predictor of later obesity. Obesity. 2009;17:1310.
- de Jong E, Schokker DF, Visscher TL, Seidell JC, Renders CM. Behavioural and socio-demographic characteristics of Dutch neighbourhoods with high prevalence of childhood obesity. Int J Pediatr Obes. 2011;6:298-305.
- Lamichhane AP, Puett R, Porter DE, Bottai M, Mayer-Davis EJ, Liese AD. Associations of built food environment with body mass index and waist circumference among youth with diabetes. Int J Behav Nutr Phys Act. 2012;9:81.
- Stovitz SD, Pardee PE, Vazquez G, Duval S, Schwimmer JB. Musculoskeletal pain in obese children and adolescents. Acta Paediatr. 2008;97:489-493.
- Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham G. Risk factors for sleep-disordered breathing in children. Associations with obesity, race, and respiratory problems. Am J Respir Crit Care Med. 1999;159:1527-1532.
- Goran MI, Ball F, Cruz M. Obesity and risk of type 2 diabetes and cardiovascular disease in children and adolescents. J Clin Epidemiol Metab. 2003;88:1417–1427.
- Wills M. Orthopedic complications of childhood obesity. Pediatr Phys Ther. 2004;16:230-235.
- Mauch M, Grau S, Krauss I, Maiwald C, Horstmann T. Foot morphology of normal, underweight and overweight children. Int J Obes. 2008;32:1068-1075.
- Hills AP, Parker AW. Gait characteristics of obese children. Arch Phys Med Rehabil. 1991;72:403-407.
- Hills AP, Parker AW. Locomotor characteristics of obese children. Child Care Health Dev. 1992;18:9-34.
- Colne P, Frelut ML, Peres G, Thoumie P. Postural control in obese adolescents assessed by limits of stability and gait initiation. Gait Posture. 2008;28:164–169.
- Nantel J, Brochu M, Prince F. Locomotor strategies in obese and non-obese children. Obesity. 2006;14:1789–1794.
- McGraw B, McClenaghan BA, Williams HG, Dickerson J, Ward DS. Gait and postural stability in obese and nonobese prepubertal boys. Arch Phys Med Rehabil. 2000;81:484–489.
- McClure AC, Tanski SE, Kingsbury J, Gerrard M, Sargent JD. Characteristics associated with low self-esteem among US adolescents. Acad Pediatr. 2010;10:238-244.