Data Collection Form

Frontal Shoulder Response in Pediatric Volunteers

• Sign parental permission form and child assent

• Sign gift card log

• Explain procedure to child / parent

• Make sure child’s clothing is appropriate

• Meets inclusion criteria

Subject # Date

Birth Month / Year Sex: M / F Arm Dominance: R / L

Anthropometry:

1.	Weight
2.	Height (Standing)
3.	Seated height
4.	Shoulder width (lat delt to lat delt)
5.	Bi-acromial Distance
6.	Clavicular Length (R side)
7.	Humeral Length (R side)
8.	Chest Width
9.	Chest Depth
10.	Chest Circumference
11.	Arm circumference (mid-bicep)

• Set up VICON (marker placement)

• Position child for ROM assessment

12.	Active ROM	Motion	Trial #1	Trial #2	Trial #3
		Flexion
		Extension
		Abduction
		Horizontal Abduction
		Horizontal Adduction
		Internal Rotation
		External Rotation
		Circumduction
13.	Passive ROM	Motion	Trial #1	Trial #2	Trial #3
		Flexion
		Extension
		Abduction
		Horizontal Abduction
		Horizontal Adduction
		Internal Rotation
		External Rotation
		Circumduction (active)

• Position child in test fixture

14.	Condition	Thorax Position	Angle of pull	Force used (N)	Trial #1	Trial #2
	No Shoulder belt	Sitting Upright	90°	50 (25 N/arm)
				150 (75 N/arm)
				300 (150 N/arm)
			135°	50 (25 N/arm)
				150 (75 N/arm)
				300 (150 N/arm)
			170°	50 (25 N/arm)
				150 (75 N/arm)
				300 (150 N/arm)
15.		Leaning Forward	90°	50 (25 N/arm)
				150 (75 N/arm)
				300 (150 N/arm)
			135°	50 (25 N/arm)
				150 (75 N/arm)
				300 (150 N/arm)
16.	Shoulder belt	Sitting Upright	90°	50 (25 N/arm)
				150 (75 N/arm)
				300 (150 N/arm)
			135°	50 (25 N/arm)
				150 (75 N/arm)
				300 (150 N/arm)
			170°	50 (25 N/arm)
				150 (75 N/arm)
				300 (150 N/arm)