Fitness+Testing+in+Pediatric+Population


 * Purpose (Clinical Question): Which type of fitness tests are best utilized in the pediatric population according to level of function? **
 * Approximately 17% (or 12.7 million) of children and adolescents aged 2—19 years are obese (CDC, 2014)
 * Health care providers, educators, and parents need to reverse this trend because it can have important health implications later in life. This is why physical fitness testing is crucial in children grades 3-12 to recognize any lower physical fitness levels and increased obesity levels.
 * Choosing the correct fitness test is important because some children may operate at higher functioning levels while other children may have a more delayed development in physical activity.
 * Fitness testing in pediatrics is important because it gives us a baseline of their current level of fitness, helps establish goals and shows their progress over time. It also targets one of the biggest health issues: childhood obesity
 * These fitness tests will provide us objective data to help with our assessments.
 * This allows physical therapists in a school or pediatric setting to set individualized exercise programs based on these results, as well as track their progress.
 * Fitness tests can also provide adolescents information about their present fitness status and allow them to compare their results with established “norms” for others of the same age and gender.

FitnessGram
 * FitnessGram is a widely used physical fitness assessment education and reporting tool
 * FitnessGram uses criterion-referenced standards to evaluate fitness performance. On the basis of these measures, students are stratified as being above or below a predetermined threshold for the healthy fitness zone (HFZ), indicating whether their level of fitness is sufficient to reduce their risk for hypokinetic diseases.One of the most important contributions of the FitnessGram is that the assessments are based on health standards for cardiorespiratory fitness, body composition,, and musculoskeletal function (Marques et al, 2015)
 * FitnessGram also enables teachers to produce personalized reports that provide information about the child’s level of health-related fitness and suggestions to improve his/her fitness profile.
 * Schools have not been implicated as a “cause” of the obesity epidemic; they are clearly viewed as being a critical part of the solution. This is due primarily to the ability to reach and influence large numbers of children in a comprehensive and systematic way (Welk et al, 2011).


 * Research: Association between Physical Activity, Sedentary Time and Healthy Fitness in Youth **
 * In (Marques et al), self-reported physical activity and sedentary time are subject to bias due to social desirability so objective assessments of physical activity and sedentary time (through an accelerometer) offer more precise estimates of the association between sedentary time, PA, and health related fitness.
 * Health related fitness was assessed through FITNESSGRAM test battery
 * The specific measures of the FITNESSGRAM are BMI, calculated from measured weight and height (kg·m-2), push-ups (upper body strength and endurance), curl-ups (abdominal strength and endurance), sit and reach (flexibility of the hamstrings and the lower back), and the Progressive Aerobic Cardiovascular Endurance Run (PACER) testing cardiorespiratory fitness. In each test, participants were classified into two zones, HFZ and risk zone (unhealthy zone), according to the FITNESSGRAM cut points based on sex- and age-related criterion-referenced standards (4).
 * Results: Being physically active increases the odds of being categorized as attaining a high level of health-related fitness.


 * Research: Manual Resistance Training in Adolescents**
 * In a study by (Dorgo, et al 2009), changes in physical fitness scores using FITNESSGRAM and body composition were used to measures adolescents through the application of manual resistance training and cardiovascular endurance training in school-based PE settings compared with adolescents attending a traditional PE program.
 * Manual resistance training (MRT) included minimal equipment because the resistance for an exercise movement is provided by 1 or more partners, and traditional weight training equipment such as bars, dumbbells, and plates are not used. Instead, benches, chairs, tables, step boxes and PVC pipes were used (Dorgo, 2009).
 * Selected components of the Fitnessgram included the 1-mile run, curl-up, trunk lift, push-up, flexed-arm hang, and modified pull-up tests and BMI calculations.
 * The major study findings were that experimental subjects in the MRT and MRT + Endurance groups showed greater improvements than the control subjects for all 6 of the selected Fitnessgram assessments (Dorgo, 2009).

FitnessGram Testing Components
 * 5 Components of Physical Fitness**
 * 1) Cardiovascular endurance
 * 2) Muscular strength
 * 3) Muscular endurance
 * 4) Muscular flexibility
 * 5) Body composition




 * PACER test or One Mile Run **

• Progressive Aerobic Cardiovascular Endurance Run (PACER) • Measures cardiovascular endurance. • Objective: Run as long as possible back and forth across a 20-meter space at a specified pace that gets faster each minute. This test is progressive in intensity and gets more difficult at the end. Strongly recommended for grades K-3 • The one-mile run can be used instead of the PACER to provide an estimate of aerobic capacity (VO2 max).Students are timed on how fast they can complete a mile. --> PACER video: https://www.youtube.com/watch?v=wyvGs-3IA9U


 * Curl-Up **

• Measures muscular strength and endurance. • Objective: Complete as many curl-ups as possible up to a maximum of 75 at a specified pace. • The curl-up with knees flexed and feet unanchored has been selected because individually these elements have been shown to a) decrease movement of the fifth lumbar vertebra over the sacral vertebrae, b) minimize the activation of the hip flexors, c) increase the activation of the external and internal obliques and transverse abdominals, and d) maximize abdominal muscle activation of the lower and upper rectus abdominals relative to disc compression (load) when compared with a variety of sit-ups --> Curl up video: https://www.youtube.com/watch?v=Z1pPlaZc8Kc&list=PLlp-3ZwsPhW09WW5TW2EudCd3XNCxwV9b

• Measures trunk extensor strength and flexibility. • Objective: Lift the upper body off the floor using the muscles of the back and hold the position to allow for measurement. • .The maximum score on this test is 12 inches. While some flexibility is important, it is not advisable (or safe) to encourage hyperextension. --> Trunk Lift Video (min 1:09): https://www.youtube.com/watch?v=PvYI3iPUHpY&spfreload=5
 * Trunk Lift **

• Measures muscular strength and endurance. • Objective: Complete as many push-ups as possible at a rhythmic pace. • Push-ups are to be completed at a elbow angle of 90 degrees. --> Push-Up Test: https://www.youtube.com/watch?v=v-EGC9jBC44
 * Push Up **

• Measures muscular strength and endurance • Objective: To complete as many pull-ups as possible. • The pull-up test is not the recommended test item for the vast majority of students because many are unable to perform even one pull-up. This test item should not be used for students who cannot perform one repetition. --> Modified Pull-Up Test (min 0:57): https://www.youtube.com/watch?v=4pbXvfxFTyI&index=11&list=PL1CB59E30244687AD
 * Pull Up **


 * Sit-and-Reach Test **
 * To measure flexibility
 * Objective: To be able to reach the specified distance on the right and left sides of the body
 * Sit and Reach (min 1:39): https://www.youtube.com/watch?v=d_NL2Pke4NM&index=8&list=PL1CB59E30244687AD


 * Shoulder Stretch **
 * To measure flexibility
 * Objective: To be able to touch the fingertips together behinh the back by reaching over the shoulder and under the elbow.
 * Shoulder Stretch: (min 1:18): https://www.youtube.com/watch?v=Vue_8KqEmkQ&list=PL1CB59E30244687AD&index=1
 * Flexed Arm Hang **
 * This test is as alternative to the push-up and measures upper-body strength.
 * Objective: To grasp the bar with palms facing away, and chin should be above bar. Number of seconds chin is held above the bar is recorded.


 * Body Mass Index **
 * Weight (kg) / height^2 (m)

For more detailed information on how to properly administer each test with detailed instructions http://www.ccsoh.us/Downloads/FG%20Test%20Administration%20Manual%20Updated%204E.pdf

FitnessGram Performance Standards







Pediatric Balance Scale
 * Some children do not meet the high standards of a Fitnessgram test and may have a mild to moderate motor impairment. The reason these children slip through the cracks is because they have developed compensations to successfully function at home or school.
 * The problem lies in that children with mild/moderate impairment can be independent but upon a closer inspection it becomes evident they lack certain basic skills. One such example would be their ability to only initiate single limb stance with only one limb in preparation for stepping onto a curb. Strong preferences or limited options may create movement strategies that are unique to given environments and appear slow, precarious, or impulsive.

Pediatric Balance Scale
 * Berg Balance Scale Modification for children with mild/moderate impairment
 * Developing the PBS as a BBS alternative.
 * 40 normal children (age 5-7). No significant difference in PBS test and re-test values.
 * Limitation-does not test overhead reach capabilities.
 * Functional activities that a child must safely and independently perform at home, school, or in the community.
 * 6 static tests, 8 dynamic tests. Score ranges from 0-56.
 * 5-level grading assessment from 0-4 with 0 being unable and 4 independent.
 * Ceiling effects noted for typically developing children seven years and older.
 * (69.1% reach maximal score of 56, 95% reach a 53)

Berg Balance Scale VS Pediatric Balance Scale
 * Pediatric Balance Scale Example**

http://www.adams12.org/files/dms/PediatricBalanceScale_3.pdf
 * For a full version of the test:**


 * PBS Normative Cutoff Scores**
 * Mild/Moderate Impairment**
 * Prader-Willi syndrome
 * Learning disabled and speech-language impaired
 * Intellectual Disability
 * Spina Bifida
 * Status post-brain resection
 * Cerebral Palsy


 * Reliability and Validity of the Pediatric Balance Scale **
 * PBS is sensitive to changes in functional balance performances and is effective for monitoring child status over time.
 * Future-could be used to assess effectiveness of PT.
 * PBS has excellent test-retest reliability, inter-rater reliability & convergent validity.
 * Moderate to good correlation to WeeFIM
 * Showed excellent predictive capabilities to GMFM-66.
 * PBS is an appropriate tool when using measures of functional balance to predict future motor function and ADL in a CP population.

WeeFIM
 * Many kids have developmental problems both cognitively and with motor skills. It is important not to overlook either of these areas when assessing our youth. The WeeFIM is one of the GOLD Standards to this day for assessing cognition and motor skills in the pediatric population.
 * In this study on the WeeFIM they added a third domain (factor) self-care to see if it would have an effect on the overall outcome of the WeeFIM scores
 * This test is quick to administer and can give you great pre/post outcome measures for kids with cognitive and/or motor development issues

WeeFIM Most Popular instrument for measuring functional mobility in children

https://www.youtube.com/watch?v=EwEsLhFJnMc
 * Often used for children with developmental disabilities (CP)
 * Measures child’s level of independence and participation in activities for daily living
 * 18 Items
 * 20 minute administration time
 * Recommended for children 6 months to 7 years
 * Can be used for kids 7 to 18 years with developmental problems
 * Used to identify changes in functional outcomes after intervention
 * Similar to PEDI (Pediatric Evaluation of Disability Inventory)
 * Good Internal Consistency
 * 95% confidence interval
 * Good reliability (Both Inter-tester and Intra-tester)
 * Used by pediatric inpatient, outpatient, and community based rehab programs


 * 3 Factors: Motor, Cognition, and Self Care**
 * 6 Domains:**
 * 1) Self Care (6)- eating, grooming, bathing, dressing upper, dressing lower, and toileting
 * 2) Sphincter Control (2)- bowel management and bladder management
 * 3) Transfers (3)- bed/chair/wheel- chair, toilet transfer, and tub transfer.
 * 4) Locomotion (2)- walking/wheelchair and stair-climbing
 * 5) Communication (2)- comprehension and expression
 * 6) Social Cognition (3)- social interaction, problem solving, and memory


 * FIM Levels**
 * __ No helper __
 * 7 Complete Independence (Timely, Safely)
 * 6 Modified Independence (Device)
 * __ Helper – Modified Dependence __
 * 5 Supervision (Subject = 100%)
 * 4 Minimal assistance (Subject = 75% or more)
 * 3 Moderate assistance (Subject = 50% or more)
 * __ Helper – Complete Dependence __
 * 2 Maximal assistance (Subject = 25% or more)
 * 1 Total assistance (Subject less than 25%)




 * Training**


 * Need to attend training for FIM and WeeFIM
 * Pass an online exam
 * Credentialing remains valid for 2 years

Early Endurance Activity Scale
 * Questionnaire completed by a parent makes it an indirect measure of physical activity
 * Indirect measures can be more cost effective and less time consuming, but the data collected are considered estimate
 * Developed to measure endurance of physical activity in children with Cerebral Palsy
 * Physical activity: bodily movement of any type (play, recreation, fitness, and sports)


 * What's Being Rated **
 * Children's Levels of Energy
 * Fatigue
 * Frequency and Need for Rest
 * Average Length of PA Engagement w/o Rest

My child has a high physical energy level and rarely needs to take rests when moving himself/herself around during daily activities and play time. Never Rarely Sometimes Often Always 1 2 3 4 5
 * The Test**
 * 11 questions with max score of 50
 * Question 7 yes/no on independent mobility
 * Examples

On average approximately how many minutes can your child move actively during play INDOOR w/o needing a rest? 0 min 1-5 min 6-10 min 11-20 min >20 min 1 2 3 4 5


 * Limitation **
 * Question interpretation
 * Overestimation of activity

Overall Overview
 * There are over 50+ tests to assess and screen the pediatric population. Choosing a test is dependent on what you’re trying to focus on, whether it is balance, endurance, strength, posture, or fine motor. The list goes on. These tests can be used in a combination with each other to compile data together and create an appropriate treatment plan.
 * FitnessGram is an assessment tool that evaluates physical performance and its use should be indicated for higher functional adolescents capable of performing advanced physical activites
 * PBS is an effective and quick test that can be used to assess mild to moderate motor impairments in children. It can be used in conjunction with other tests, such as WeeFIM.
 * WeeFIM is a highly utilized pediatric outcome tool that be used in an inpatient, outpatient or community based rehab setting.
 * The Early Endurance Activity Scale (EASE) is a parent-report questionnaire, to measure physical activity endurance in young children with cerebral palsy (CP) aged 1.5 to 5 years. Even though there’s inherent bias and objective measures of physical activity intensity, duration, endurance, and frequency should be further investigated, EASE does provides a systematic way to describe physical activity patterns and behaviors in young children with CP.
 * Choosing a correct fitness test is dependent on the population, age group, and the goals that are trying to be accomplished.

References

Centers for Disease Control and Prevention. (2014). Childhood Obesity Facts. Retrieved from http://www.cdc.gov/obesity/downloads/PA_2011_WEB.pdf

Chen, C., Shen, I., Chen, C., Wu, C., Liu, W., & Chung, C. (2013). Validity, responsiveness, minimal detectable change, and minimal clinically important change of Pediatric Balance Scale in children with cerebral palsy. Research in Developmental Disabilities, 34(3), 916–22. http://doi.org/10.1016/j.ridd.2012.11.006

Dorgo, S., King, G., Candelaria, N., Bader, J., Brickey, G., & Adams, C. (2009). Effects of manual resistance training on fitness in adolescents. Journal Of Strength & Conditioning Research (Lippincott Williams & Wilkins), 23(8), 2287-2294 8p. doi:10.1519/JSC.0b013e3181b8d42a

Franjoine, M. R., Gunther, J. S., & Taylor, M. J. (2003). Pediatric balance scale: a modified version of the berg balance scale for the school-age child with mild to moderate motor impairment. Pediatric Physical Therapy : The Official Publication of the Section on Pediatrics of the American Physical Therapy Association, 15(2), 114–28. []

Meredith, M. D., & Welk, G. J. (2013). FITNESSGRAM/ACTVITYGRAM Test Administration Manual (Rep.). Retrieved April 4, 2016, from The Cooper Institue website: http://www.ccsoh.us/Downloads/FG Test Administration Manual Updated 4E.pdf

Marques, A., Santos, R., Ekelund, U., & Sardinha, L. B. (2015). Association between Physical Activity, Sedentary Time, and Healthy Fitness in Youth. Medicine & Science In Sports & Exercise, 47(3), 575-580 6p. doi:10.1249/MSS.0000000000000426

Park, E., Kim, W., & Choi, Y. (2013). Factor analysis of the WeeFIM in children with spastic cerebral palsy. Disability & Rehabilitation, 35(17), 1466-1471. Raad, J. (2015, September 4). Rehab Measures - Pediatric Balance Scale. Retrieved April 04, 2016, from http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=1258

Welk, G. J., Going, S. B., Morrow, J. R., & Meredith, M. D. (2011). Development of new criterion-referenced fitness standards in the FITNESSGRAM® program: rationale and conceptual overview. American Journal of Preventive Medicine, 41(4 Suppl 2), S63–7. []

Westcott McCoy, S., Yocum, A., Bartlett, D. J., Mendoza, J., Jeffries, L., Chiarello, L., & Palisano, R. J. (2012). Development of the Early Activity Scale for Endurance for children with cerebral palsy. Pediatric Physical Therapy : The Official Publication of the Section on Pediatrics of the American Physical Therapy Association, 24(3), 232– 40. http://doi.org/10.1097/PEP.0b013e31825c16f6