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## Complete Summary

#### GUIDELINE TITLE

Evidence-based care guideline for loss of elbow motion following surgery
or trauma in children aged 4 to 18.

#### BIBLIOGRAPHIC SOURCE(S)

Cincinnati Children\'s Hospital Medical Center. Evidence-based care
guideline for loss of elbow motion following surgery or trauma in
children aged 4 to 18. Cincinnati (OH): Cincinnati Children\'s Hospital
Medical Center; 2007 Dec 21. 9 p. \[26 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Loss of elbow motion following surgery or trauma, including:

-   Fracture of distal humerus

-   Supracondylar humeral fracture

-   Condyle and epicondyle fracture

-   Elbow dislocations

-   Olecranon fracture

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Prevention\
Rehabilitation\
Treatment

#### CLINICAL SPECIALTY

Orthopedic Surgery\
Pediatrics\
Physical Medicine and Rehabilitation

#### INTENDED USERS

Occupational Therapists\
Patients\
Physical Therapists\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To optimize elbow function through long term maintenance of
    increased active elbow range of motion

-   To increase elbow strength in children who have been immobilized
    after elbow surgery or trauma

-   To minimize time spent in therapy

-   To increase coordination and consistency of care provided by
    therapists

-   To maintain and improve family satisfaction

#### TARGET POPULATION

These guidelines are intended for the use in patients aged 4 through 18
years of age who present with loss of elbow motion following surgery or
trauma including the following:

-   Fracture of distal humerus

-   Supracondylar humeral fracture

-   Condyle and epicondyle fracture

-   Elbow dislocations

-   Olecranon fracture

These guidelines are not intended for use in patients with the
following:

-   Radial head fracture

-   Radial neck fracture

-   Nerve damage associated with injury

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis and Evaluation**

1.  History and physical exam

2.  Clinical assessment

**Management/Treatment**

1.  Occupational and physical therapy:

    -   Inflammatory/acute phase: range of motion, strengthening,
        superficial cold

    -   Fibroplastic/subacute phase: range of motion, strengthening,
        superficial heat, ultrasound, superficial cold

    -   Remodeling/return to activity phase: range of motion,
        strengthening, superficial heat, ultrasound, superficial cold

2.  Splinting

    -   Timeframe for splinting

    -   Types of splints

        -   Static progressive

        -   Serial static

        -   Dynamic

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3.  Discharge criteria

4.  Follow up consultation

5.  Patient and family education

#### MAJOR OUTCOMES CONSIDERED

-   Range of motion (ROM)

-   Equal strength between extremities

-   Functional ability

-   Patient and family satisfaction

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

To select evidence for critical appraisal by the group for the
development of this guideline, Pubmed, OVID (Medline, Cinahl, All EBM
Reviews - Cochrane DSR, ACP Journal Club, DARE and CCTR), Pedro, OT
Seeker and OT CATS databases were searched to generate an unrefined,
\"combined evidence\" database using a search strategy focused on
answering clinical questions relevant to this Loss of Elbow Motion
Following Surgery or Trauma (see Appendix  \'Initial Clinical Questions
used to guide search and selection of evidence\' in the original
guideline document) and employing a combination of Boolean searching on
human-indexed thesaurus terms (MeSH headings using an OVID Medline
interface) and \"natural language\" searching on searching on
human-indexed thesaurus terms (MeSH headings using an OVID Medline
interface) and \"natural language\" searching on words in the title,
abstract, and indexing terms. Additionally a search was done on the on
the web including the website
[www.googlescholar.com](http://www.googlescholar.com/). Many search
terms were used as seven therapists did the searching. The search was
done from February to May of 2006. Terms that were used to search
relating to the anatomy of the elbow were as follows: elbow, distal
humerus, supracondylar, radial head, olecranon, upper extremity. These
terms were combined with terms describing the pathology: injury,
fracture, dislocation, trauma, adhesions, contracture. Other terms used
include: immobilization, complications, therapy, splint, pediatric,
rehabilitation, range of motion, stretching, goniometer, modalities,
reliability and validity. The citations were reduced by eliminating
duplicates, non-English articles, and articles deemed inappropriate for
the purpose of this project. Various combinations of these terms were
used of the above named databases and the appropriate articles were
retrieved, read, reviewed and appraised by members of the team. There
were approximately 55 articles pulled from these searches that were
culled by team members to find those that best aligned with this
guideline\'s clinical questions (see Appendix in the original guideline
document). After the database search was exhausted, the team found other
appropriate articles and book chapters by scanning the reference lists
of the reviewed articles. The team decided that all levels of evidence
would be appropriate as there was not much evidence relating to the
specific population at the time of the search. During the course of the
guideline development, additional clinical questions were generated and
subjected to the search process, and some relevant review articles and
adult literature were utilized.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Recommendations have been formulated by a consensus process directed by
best evidence, patient and family preference and clinical expertise.
During formulation of these recommendations, the team members have
remained cognizant of controversies and disagreements over the
management of these patients. They have tried to resolve controversial
issues by consensus where possible and, when not possible, to offer
optional approaches to care in the form of information that includes
best supporting evidence of efficacy for alternative choices.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guidelines have been reviewed and approved by clinical experts not
involved in the development process, senior management, other
appropriate hospital committees, and other individuals as appropriate to
their intended purposes.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Each recommendation is followed by evidence classification (A-X)
identifying the type of supporting evidence. Definitions for the types
of evidence are presented at the end of the \"Major Recommendations\"
field.

**History and Physical Exam**

It is recommended that a thorough history will be taken from the patient
and/or parent regarding:

-   Mechanism of injury

-   Type of injury

-   Any surgery-type of procedure

-   Immobilization (duration, date removed)

-   Functional goals of patient and family (Local Consensus \[**E**\])

**Clinical Assessment**

Recommended assessment of the following:

-   Active (AROM) and passive range of motion (PROM) of shoulders,
    elbows, forearms and wrists

-   Joint end feel

-   Sensation

-   Visual inspection of surgical site

-   Girth measurements (if appropriate)

-   Strength of shoulders, elbows (if appropriate), forearms, wrists and
    grip (Davila & Johnston-Jones, 2006 \[**S**\], Local Consensus
    \[**E**\])

**Recommended Outpatient Occupational and Physical Therapy
Interventions**

It is the recommendation of these therapists that the patient with a
post-traumatic immobilized elbow with impaired motion and/or strength be
referred for outpatient occupational or physical therapy interventions
as soon as possible after the immobilization period. It has been shown
that patients who have been allowed early mobilization or referred to
physical therapy sooner have gone onto have, fewer complications, fewer
residual symptoms, and faster gains in range of motion and strength than
those who have delayed motion and/or therapy (Nash et al., 2004
\[**M**\]; Keppler et al., 2005 \[**C**\]; Dias et al., 1987 \[**C**\]).
The following clinical guidelines are based upon the best research
available at this time related to the basic science of healing and
principles of rehabilitation. It is recommended that this will be
utilized from day one when a patient comes out of their cast and
incorporated into their plan of care.

It is recommended that a clinic based physical therapy plan be
initiated, as indicated by the patient\'s current impairments. It is
recommended that the patient and family are instructed in a home program
of range of motion and strengthening and that they will be followed at
least once weekly by physical therapy for progression of program until
goals are met or patient\'s progress has plateaued (Friedrich, Cermack,
& Maderbacher, 1996 \[**C**\], Griffith, 2002 \[**E**\]).

1.  **Inflammatory/Acute Phase (0 to 2 weeks after injury)**

    -   **Recommended Goals**: Control pain, minimize and prevent edema,
        protect healing structures, maintain stability, maintain and
        progress (gently) range of motion (ROM).

    -   **Recommended ROM Interventions**: Begin active range of motion
        (AROM) and active assisted range of motion (AAROM) at the elbow
        when stability has been achieved; begin AROM of all non-involved
        joints; AROM and AAROM will promote healing of bone and
        articular cartilage, it will also help increase the tensile
        strength of soft tissues and minimize intra-articular adhesions
        (Davila & Johnston-Jones, 2006 \[**S**\]).

    -   **Recommended Strengthening Interventions**: Isometrics at the
        elbow musculature (only if not contraindicated); grip
        strengthening exercises (Davila & Johnston-Jones, 2006
        \[**S**\]).

    -   **Recommended Modalities**: Superficial cold modalities to help
        reduce the acute inflammation (Nadler, Weingand & Kruse, 2004
        \[**S**\]).

    -   **Recommended Precautions**: It is recommended to avoid
        pronation/supination with collateral ligament involvement and
        avoid excessive pain and stress with AROM and AAROM (Davila &
        Johnston-Jones, 2006 \[**S**\], Local Consensus \[**E**\]).

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2.  **Fibroplastic/Subacute Phase (2 to 8 weeks after injury)**

    -   **Recommended Goals**: Continue to decrease edema, increase ROM,
        increase function, increase strength

    -   **Recommended ROM Interventions**: Continue with AROM and AAROM
        with increased force of contraction; recommended to begin gentle
        passive range of motion (PROM) at 6 weeks postop/injury (Local
        Consensus \[**E**\]); recommended technique for PROM is be slow
        prolonged stretching with at least a 30 second hold, doing 4 to
        5 repetitions (Bandy & Irion, 1994 \[**D**\]).

    -   **Recommended Strengthening Interventions**: Progression to
        isotonic strengthening exercises (Davila & Johnston-Jones, 2002
        \[**E**\]) for healing fractures, weight-bearing exercises will
        help increase bone mineral density with healing bone (MacKelvie,
        Khan & McKay, 2002 \[**M**\]).

    -   **Recommended Modalities**: Superficial heat (20 minutes) or
        ultrasound may be used immediately prior to stretching to
        increase tissue extensibility (Draper et al., 1998 \[**B**\];
        Draper & Ricard, 1995 \[**C**\]; Taylor, Waring, & Brashear,
        1995 \[**C**\]); superficial cold at end of session to reduce
        any acute inflammation of tissue (Nadler, Weingand & Kruse, 2004
        \[**S**\]).

    -   **Precautions**: It is recommended that the therapist take
        caution with amount of force applied to target tissue; PROM
        force will be within tissue tolerance (comfortable, short of
        pain) so as to lengthen and remodel the tissue, not cause
        inflammatory response (Bandy & Irion, 1994 \[**D**\]; Davila &
        Johnston-Jones, 2006 \[**S**\]).

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3.  **Remodeling/Return to Activity Phase (2 to 6 months after injury)**

    -   **Recommended Goals**: To continue to increase ROM, strength and
        function; progress to sport specific exercises as indicated

    -   **Recommended ROM**: Continue with above interventions of AROM,
        AAROM and PROM; may introduce joint mobilization techniques if
        loss of motion can be attributed to joint stiffness (Michlovitz,
        Harris, & Watkins, 2004 \[**M**\]; Davila & Evelyn, 2002
        \[**E**\])

    -   **Recommended Strengthening**: Progressive resistive
        strengthening with weights and bands are appropriate

    -   **Recommended Modalities**: Superficial heat (20 minutes) or
        ultrasound (3MHz, 1.5 W/cm^2^ for 7 minutes) can be used
        immediately prior to stretching to increase tissue extensibility
        (Draper et al., 1998 \[**B**\]; Draper & Ricard, 1995 \[**C**\],
        Taylor Waring & Brashear, 1995 \[**C**\]); superficial cold at
        end of session to reduce any acute inflammation of tissue
        (Nadler, Weingand & Kruse, 2004 \[**S**\]).

    -   **Precautions**: It is recommended that joint mobilization
        techniques be delayed until 6 to 8 weeks after injury or
        fracture union is evident (be in close contact with referring
        physician regarding implementation of this intervention) (Local
        Consensus \[**E**\]).

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4.  **Splinting**

> It is recommended to wait until sufficient healing and fracture
> stability has occurred prior to initiating splinting to regain ROM in
> order to avoid pain, inflammation, ligamentous insufficiency, and
> heterotropic ossification (Szekeres, 2006 \[**O**\], Chinchalkar &
> Szekeres, 2004 \[**S**\]). Splinting is most effective if initiated in
> the first 3 months, moderately effective from 3 to 6 months, and has
> variable effectiveness when initiated 6 to 12 months post injury
> (Morrey, 2002 \[**E**\]).
>
> **Contraindications**: Poor skin quality, bony blocks, loose bodies,
> or any other intra-articular restrictions seen on x-ray. Discontinue
> splint use if sensory or motor changes occur with use (Zander & Healy,
> 1992 \[**C**\], Morrey, 2002 \[**E**\]). Close communication with the
> referring physician is essential to ensure safe use of splinting and
> casting.

5.  **Recommended Timeframe for Splinting**

    A.  Inflammatory Phase (0 to 2 weeks), splinting and casting can be
        used to protect the joint (Chinchalkar & Szekeres, 2004
        \[**S**\]).

    B.  Fibroplastic Phase (2 to 8 weeks) splinting and casting may be
        used to help restore or gain range of motion.

    C.  Remodeling Phase (2 to 6 months) progressively increase ROM with
        splinting to enhance collagen orientation and plastic elongation
        of tissues (Davila & Johnston-Jones, 2006 \[**S**\]; Chinchalkar
        & Szekeres, 2004 \[**S**\]).

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6.  **Types of Splints**

    A.  **Static Progressive Splints**: These splints operate on
        principle of stress relaxation (Gelinas et al., 2000 \[**C**\];
        Bonutti et al., 1994 \[**D**\]) and are used to regain ROM.
        Examples: Joint Active Systems (JAS), turnbuckle splints

> *Pro*: Can be worn for shorter periods of time, worn to patient
> comfort, adjustable tension. Operating on principle of stress
> relaxation, there may be less likelihood of irritation and
> inflammation (Morrey, 2002 \[**E**\]). This type of brace may be more
> effective for gaining extension (Davila & Johnston-Jones, 2006
> \[**S**\]). JAS makes one splint for flexion and extension
>
> *Con*: Rely on patient to continuously adjust the splint
>
> [Static Progressive Splints Guidelines]{.underline}:

1.  Recommend wear splint 30 minutes to 2 hours 3 to 4 times per day
    (Bonutti et al., 1994 \[**D**\]; Chinchalkar & Szekeres, 2004
    \[**S**\]; Davila & Evelyn, 2002 \[**E**\]).

2.  Recommend 20 hours wear time, including use at night (Gelinas et
    al., 2000 \[**C**\]; Morrey, 2002 \[**E**\]).

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B.  **Serial Static Splinting**: (also includes serial casting and night
    extension splints)

> *Pro*: night splints are recommended for use in combination with other
> splinting to help maintain gains made through the day (Davila &
> Johnston-Jones, 2006 \[**S**\]; Chinchalkar & Szekeres, 2004
> \[**S**\]).
>
> [Serial Static Splinting Guidelines]{.underline}:
>
> Recommend night splinting to maintain gained motion and compliments
> use of static progressive stretches (Chinchalkar & Szekeres, 2004
> \[**S**\]). It is also helpful if flexion contracture is less than 30°
> (Davila & Johnston-Jones, 2006 \[**S**\]).

C.  **Dynamic Splinting**: These splints operate on the principle of
    creep and usually requires 8 to 12 hours of wear time per session
    (Bonutti et al., 1994 \[**D**\]).

> *Pro*: May be more effective for gaining flexion during the Remodeling
> Phase (Davila & Johnston-Jones, 2006 \[**S**\])
>
> *Con*: Operating on principle of creep, this may cause inflammation,
> which may lead to additional swelling and scarring. Requires longer
> wear time (Bonutti et al., 1994 \[**D**\]; Morrey, 2002 \[**E**\]).
> Need separate splints for flexion and extension
>
> [Dynamic Splinting Guidelines]{.underline}:
>
> No specific recommendations available in the peer reviewed literature.
> Dynasplint recommends extended wear time of at least 8 to 10 hours
> (Dynasplint_Systems, 1996 \[**E**\]).

7.  **Cincinnati Children\'s Hospital Medical Center Occupational
    Therapist/Physical Therapist (CCHMC OT/PT) Recommendation for Splint
    and Brace Use**:

    A.  It is recommended that night splinting be considered for soft
        tissue restrictions if there is a lack of progress after 2 weeks
        of physical therapy.

    B.  Also recommended is use of static progressive splint for flexion
        or extension contractures if there is a soft tissue restriction
        and there is a lack of sufficient progress after 2 weeks of
        intervention. One example of this type of brace is the JAS.
        Static progressive is the splint of choice for this situation;
        however, dynamic splinting (Dynasplint_Systems, 1996 \[**E**\])
        can be considered if necessary (insurance will not reimburse
        static progressive splint, or MD will not refer this type of
        brace, patient/family preference or patient/family will not be
        able to utilize static progressive splint properly) (Local
        Consensus \[**E**\]).

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8.  **Recommended Discharge Criteria**

    A.  Equal ROM of involved and uninvolved elbow

    B.  Strength within functional limits or equal to the uninvolved
        extremity (Local Consensus\[**E**\]).

    C.  Meet patient/family goals for occupational/physical therapy

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9.  **Consults**

    A.  It is recommended that contact with the patient\'s medical
        doctor for a referral to OT for evaluation and possible splint
        fabrication if a patient exhibits significant lack of motion of
        the hand and/or wrist due to nerve damage (Griffith, 2002
        \[**E**\], Local Consensus \[**E**\]).

    B.  It is recommended that if a patient exhibits a hard end feel or
        has not shown progress for 4 to 6 weeks, they be referred back
        to their physician (Davila & Johnston-Jones, 2006 \[**S**\],
        Local Consensus \[**E**\]).

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10. **Education**

> It is recommended that education for the patient and family:

-   Begin upon initial evaluation and continue throughout the course of
    occupational/physical therapy services

-   Be geared to the developmental age of the patient and the learning
    abilities of the family/caregivers

-   Address relevant topics such as treatment plan, expected progress
    and outcomes, recreational and functional activities and selection
    of splinting/bracing options

**Definitions**:

**Evidence Grading Scale**

A: Randomized controlled trial: large sample\
B: Randomized controlled trial: small sample\
C: Prospective trial or large case series\
D: Retrospective analysis\
E: Expert opinion or consensus\
F: Basic laboratory research\
S: Review article\
M: Meta-analysis or systematic review\
Q: Decision analysis\
O: Other evidence

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=12194)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified for each recommendation
(see \"Major Recommendations\").

**Evidence Grading Scale**

A: Randomized controlled trial: large sample\
B: Randomized controlled trial: small sample\
C: Prospective trial or large case series\
D: Retrospective analysis\
E: Expert opinion or consensus\
F: Basic laboratory research\
S: Review article\
M: Meta-analysis or systematic review\
Q: Decision analysis\
O: Other evidence

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate management of loss of elbow motion following surgery or
trauma to enable:

-   Optimal elbow function

-   Increased elbow strength

-   Minimization of time spent in therapy

-   Increased coordination and consistency of care by therapists

-   Improved patient and family satisfaction

#### POTENTIAL HARMS

Dynamic splinting - Operating on principle of creep, this may cause
inflammation, which may lead to additional swelling and scarring.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Splinting is contraindicated in the following conditions: poor skin
quality, bony blocks, loose bodies, or any other intra-articular
restrictions seen on x-ray.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

These recommendations result from review of literature and practices
current at the time of their formulations. This Guideline does not
preclude using care modalities proven efficacious in studies published
subsequent to the current revision of this document. This document is
not intended to impose standards of care preventing selective variances
from the guidelines to meet the specific and unique requirements of
individual patients. Adherence to these recommendations is voluntary.
The physician in light of the individual circumstances presented by the
patient must make the ultimate judgment regarding the priority of any
specific procedure.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Appropriate companion documents have been developed to assist in the
effective dissemination and implementation of the guideline.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Cincinnati Children\'s Hospital Medical Center. Evidence-based care
guideline for loss of elbow motion following surgery or trauma in
children aged 4 to 18. Cincinnati (OH): Cincinnati Children\'s Hospital
Medical Center; 2007 Dec 21. 9 p. \[26 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2007 Dec

#### GUIDELINE DEVELOPER(S)

Cincinnati Children\'s Hospital Medical Center - Hospital/Medical Center

#### SOURCE(S) OF FUNDING

Cincinnati Children\'s Hospital Medical Center

#### GUIDELINE COMMITTEE

Loss of Elbow Motion OT/PT Guideline Team 2006\--2007

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Cincinnati Children\'s Hospital Medical Center Physicians:* Eric Wall,
MD, Director of Orthopaedic Surgery

*Division of Occupational Therapy and Physical Therapy*: Christopher
Kovacs, PT, DT, CSCS; Rachel Heyl, PT, MEd, ATC; Mark Paterno, PT, MS,
MBA, SCS, ATC; Barb Nolte, PT; Chad Cherny, PT, MS, CSCS; Julie Tissot,
PT, DPT; Carol Burch, PT, DPT; Rebecca Reder, OTR/L, OTD

*Division of Health Policy & Clinical Effectiveness Support*: Eduardo
Mendez, RN, MPH, Dir. Evidence-Based Care, Facilitator

*Ad Hoc Advisor*: Barbarie Hill, Library Services

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The guideline was developed without external funding. All Team members
and Clinical Effectiveness support staff listed have declared whether
they have any conflict of interest and none were identified.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Cincinnati Children\'s Hospital
Medical
Center](http://www.cincinnatichildrens.org/svc/dept-div/health-policy/ev-based/default.htm).

Print copies: For information regarding the full-text guideline, print
copies, or evidence-based practice support services contact the
Children\'s Hospital Medical Center Health Policy and Clinical
Effectiveness Department at <HPCEInfo@chmcc.org>.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on May 12, 2008. The
information was verified by the guideline developer on May 21, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original full-text guideline, which is
subject to the following copyright restrictions:

Copies of [Cincinnati Children\'s Hospital Medical Center
(CCHMC)](http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/default.htm)
Evidence-Based Clinical Practice Guidelines (EBCG) are available online
and may be distributed by any organization for the global purpose of
improving child health outcomes. Examples of approved uses of CCHMC\'s
EBCG include the following:

-   Copies may be provided to anyone involved in the organization\'s
    process for developing and implementing evidence-based care
    guidelines.

-   Hyperlinks to the CCHMC website may be placed on the organization\'s
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-   The EBCG may be adopted or adapted for use within the organization,
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-   Copies may be provided to patients and the clinicians who manage
    their care.

Notification of CCHMC at <HPCEInfo@cchmc.org> for any EBCG adopted,
adapted, implemented or hyperlinked to by a given organization and/or
user, is appreciated.

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008