Oral motor functioning, frequency of swallowing and drooling in normal children and in children with cerebral palsy

Attempts to eliminate drooling in children with cerebral palsy have ranged from speech therapy to radical surgery. Drooling primarily results from an overflow of saliva from the mouth due to dysfunctional voluntary oral motor activity, improper swallowing, or oral sphincter deficits and rarely from hypersalivation. A study was undertaken to determine typical orofacial electromyographic patterns and swallowing frequencies of normal children and children with cerebral palsy with oral involvement who do, and who do not drool, as well as to determine the correlation between swallowing frequency and drooling rate. Results suggest that drooling in the pediatric cerebral palsy population is caused by both inefficient and infrequent swallowing.     

脑瘫患儿吞咽障碍及其与粗大运动功能分级的关系

目的探讨脑瘫患儿吞咽障碍的特点及其与粗大运动功能分级的关系。方法对2009年6月～2010年6月在本院脑瘫康复中心门诊及住院治疗的脑瘫患儿进行吞咽障碍调查、口运动评估和粗大运动功能评估,分析不同粗大运动功能分级的脑瘫患儿的吞咽问题。结果105例脑瘫患儿中,58例(56.2%)存在吞咽障碍,其中21.9%为轻度吞咽困难,34.3%为中重度吞咽困难。不同粗大运动功能分级 (Gross Motor Function Classification System, GMFCS)的吞咽障碍调查(Dysphagia Disorders Survey, DDS)及口运动评分不同(P<0.001)。DDS和口运动评分与GMFCS水平的相关系数分别为0.767和-0.504(P<0.01)。不同GMFCS分级的吞咽障碍和口运动障碍不同(P<0.001),DSS分级、口运动障碍和GMFCS分级呈正相关关系(r=0.55, r=0.27)。结论脑瘫患儿吞咽障碍主要发生在口腔期,GMFCS水平越高,吞咽障碍和口运动障碍的比例越高,程度越重,GMFCS水平Ⅳ～Ⅴ级者吞咽障碍和口运动障碍更突出。     

苯海索在小儿脑性瘫痪肌张力障碍治疗中的应用

肌张力障碍是脑瘫患儿常见的临床表现,它可致运动功能障碍、言语功能障碍、吞咽困难及流涎。苯海索(安坦)是一种中枢性抗胆碱药,它用于治疗成人肌张力障碍的历史悠久,但治疗小儿脑瘫肌张力障碍的临床经验相对较少。本文就苯海索治疗小儿脑瘫肌张力障碍的疗效、用法用量、不良反应及作用机制进行综述。     

Associations Between Spontaneous Swallowing Frequency at Admission,Dysphagia, and Stroke-Related Outcomes in Acute Care

ObjectiveTo expand the scope of prior spontaneous swallowing frequency analysis (SFA) studies, by evaluating the role of SFA in dysphagia-and stroke-related outcomes at acute stroke discharge.DesignPeriod prevalence study.SettingTertiary care university hospital.ParticipantsPatients with acute stroke (N=96).InterventionsSubjects were screened for dysphagia using SFA. Mode of screening was 24 hours from identified stroke onset. All patients completed dysphagia- and stroke-related assessments. Patients were followed to discharge from acute care, and admission SFA was compared with status at discharge.ResultsLower SFA rates at admission were significantly associated with presence of dysphagia. Lower SFA rates were also associated with persistent dysphagia and restricted diet at discharge. The SFA rates were lower for patients with identified aspiration on fluoroscopic swallowing study. Negative stroke-related outcomes from acute care were associated with lower SFA rates including disability at admission, disability and handicap at discharge, and institutionalization at discharge. Regression analysis identified SFA as an independent predictor of the negative composite outcome of death-disability-institutionalization.ConclusionsSwallowing frequency analysis not only has a high accuracy of dysphagia identification in acute stroke and relates to dysphagia severity, but it is also associated with multiple dysphagia- and stoke-related outcomes from acute care. Early poststroke dysphagia identification with SFA may lead to earlier and more effective interventions targeted at identified negative stroke outcomes.     

神经肌肉电刺激治疗脑瘫患儿流涎症的临床观察

目的探讨神经肌肉电刺激（NMES）对脑瘫患儿流涎的影响。方法43例脑瘫流涎患儿分为NMES组（n=22）及对照组（n=21）,两组常规治疗相同,NMES组同时给予NMES治疗。分别于治疗前及治疗8周后采用教师流涎分级法(TDS)评定患儿流涎情况。结果NMES组与对照组有显著性差异（P<0.05）。结论NMES可以改善脑瘫患儿流涎,促进其吞咽功能。     

The Pediatric Version of the Eating Assessment Tool: a caregiver administered dyphagia-specific outcome instrument for children

Purpose: To develop and evaluate the psychometric properties of the Pediatric version of the caregiver administered Eating Assessment Tool.

Methods: The study included developmental phase and reported content, criterion validity, internal consistency and test–retest reliability of the Pediatric Eating Assessment Tool. Literature review and the original Eating Assessment Tool were used for line-item generation. Expert consensus assessed the items for content validity over two Delphi rounds. Fifty-one healthy children to obtain normative data and 138 children with cerebral palsy to evaluate test–retest reliability, internal consistency, and criterion validity were included. The Penetration-Aspiration Scale was used to assess criterion validity.

Results: All items were found to be necessary. Content validity index was 0.91. The mean score of Pediatric Eating Assessment Tool for healthy children and children with cerebral palsy was 0.26?±?1.83 and 19.5?±?11, respectively. The internal consistency was high with Cronbach’s alpha =0.87 for test and retest. An excellent correlation between the Pediatric Eating Assessment Tool and Penetration-Aspiration score for liquid and pudding swallowing was found (p?r?=?0.77; p?r?=?0.83, respectively). A score >4 demonstrated a sensitivity of 91.3% and specificity of 98.8% to predict penetration/aspiration.

Conclusions: The Pediatric Eating Assessment Tool was shown to be a valid and reliable tool to determine penetration/aspiration risk in children.

• Implications for rehabilitation

• The pediatric eating assessment tool: a new dyphagia-specific outcome survey for children.

• The Pediatric Version of the Eating Assessment Tool is a dysphagia specific, parent report outcome instrument to determine penetration/aspiration risk in children.

• The Pediatric Version of the Eating Assessment Tool has good internal consistency, test–retest reliability and criterion-based validity.

• The Pediatric Version of the Eating Assessment Tool may be utilized as a clinical instrument to assess the need for further instrumental evaluation of swallowing function in children.

     

An investigation of the factors affecting handwriting performance in children with hemiplegic cerebral palsy

Purpose. This study investigated the effects of sensory – perceptual – motor and cognitive functions on handwriting performance in primary-school children with left-hemiplegic cerebral palsy, compared with that of their healthy peers.

Methods. The study included 26 children aged 8 – 12 years with left-hemiplegic cerebral palsy and 32 typically developing children of similar age with dominant right hand. The Minnesota Handwriting Assessment was used to evaluate handwriting ability. The Bruininks – Oseretsky Test of Motor Proficiency was used to assess motor performance. Cognitive function was assessed by the Loewenstein Occupational Therapy Cognitive Assessment. The Ayres Southern California Sensory Integration Tests were used to assess visual perception, kinaesthesia, and graphesthesia.

Results. Statistically significant differences were found between the two groups in sensory-perceptual-motor and cognitive function and in handwriting ability (p < 0.05). There were also significant correlations between handwriting parameters and upper-extremity speed and dexterity, proprioception, bilateral coordination, visual and spatial perception and, visual-motor organisation in children with cerebral palsy (p < 0.05).

Conclusions. The results showed that left-hemiplegic children with cerebral palsy whose right sides were dominant were significantly less competent at handwriting than their right-dominant, healthy peers. It was found that the impairment in proprioception seen in the non-hemiplegic side in children with cerebral palsy, and also the impairment in bilateral coordination, speed and dexterity of the upper extremities, visual and spatial perception, visual-motor organization, and tactile-sensory impairments negatively affected their handwriting skills. In the treatment approaches for children with hemiplegic cerebral palsy, comprehensive sensory – perceptual – motor assessments that involve both extremities must be performed in detail at the earliest possible stage, in order to minimize the existing problems with early-treatment policies. Developing the sensory – perceptual – motor and cognitive function of hemiplegic children would thus be possible, and they would be able to adapt to the same primary-school curriculum as their healthy peers.     

脑梗死后认知-情感、感觉缺损对吞咽功能恢复的影响

目的：探讨认知功能缺损、感觉障碍对脑梗死伴吞咽功能障碍并进行吞咽功能训练的患者吞咽功能恢复的影响.方法：34例脑梗死并发摄食-吞咽功能障碍患者,根据MMSE认知功能评定将患者分为吞咽功能障碍合并认知功能缺损组16例（A组）,单纯吞咽功能障碍组18（B组）.B组患者给予吞咽功能训练并行针灸治疗,A组在B组治疗方法的基础上进行认知功能的评定、训练和心理疏导.结果：治疗前洼田氏评分A组与B组比较差异有显著性意义（P＜0.05）,1个月后两组吞咽评定与自身治疗前相比差异有显著性意义（P＜0.05）,但两组间洼田氏评分比较差异无显著性意义（P＞0.05）.治疗前A组的颜面失用/流涎、失语、口腔感觉程度与B组相比差异有显著性意义（P＜0.05）;A组在认知功能训练后MMSE评定与自身治疗前相比有明显提高（P＜0.05）,治疗前后认知功能评分与吞咽障碍等级均呈负相关（相关系数分别为：-0.650和-0.51）.结论：脑梗死后认知功能缺损的存在可加重吞咽功能障碍的程度,认知功能的改善可促进吞咽功能的恢复.     

An investigation of the factors affecting handwriting skill in children with hemiplegic cerebral palsy*

Purpose.?This study investigated the effects of sensory-perceptual-motor and cognitive functions on handwriting skill in primary-school children with left-hemiplegic cerebral palsy, compared with that of their healthy peers.

Methods.?The study included 26 children aged 8–12 years with left hemiplegic cerebral palsy and 32 typically developing children of similar age with dominant right hand. The Minnesota Handwriting Assessment was used to evaluate handwriting skill. The Bruininks–Oseretsky Test of Motor Proficiency was used to assess motor performance. Cognitive function was assessed by the Lowenstein Occupational Therapy Cognitive Assessment. The Ayres Southern California Sensory Integration Tests were used to assess visual perception, kinaesthesia and graphesthesia.

Results.?Statistically significant differences were found between the two groups in sensory-perceptual-motor and cognitive function and handwriting skill (p?<?0.05). There were also significant correlations between handwriting parameters and upper-extremity speed and dexterity, proprioception, bilateral coordination, visual and spatial perception and, visual-motor organisation in children with cerebral palsy (p?<?0.05).

Conclusions.?The results showed that left-hemiplegic children with cerebral palsy whose right sides were dominant were significantly less competent at handwriting than their right-dominant, healthy peers. It was found that the impairment in proprioception seen in the non-hemiplegic side in children with cerebral palsy, and also the impairment in bilateral coordination, speed and dexterity of the upper extremities, visual and spatial perception, visual-motor organization, and tactile-sensory impairments negatively affected their handwriting skills. In the treatment approaches for children with hemiplegic cerebral palsy, comprehensive sensory-perceptual-motor assessments that involve both extremities must be performed in detail at the earliest possible stage, in order to minimize the existing problems with early-treatment policies. Developing the sensory-perceptual-motor and cognitive function of hemiplegic children would thus be possible, and they would be able to develop handwriting skill as a tool for their academic lives as healthy peers.     

An investigation of the relationship of drooling with nutrition and head control in individuals with quadriparetic cerebral palsy

[Purpose] The aim of the present study was to investigate the relationship of drooling, nutrition, and head control in individuals with quadriparetic cerebral palsy. [Subjects and Methods] Fifty-six individuals between the ages 2 and 15 diagnosed with spastic quadriparetic cerebral palsy and their families/caretakers were included in the study. Drooling severity and frequency of individuals was evaluated by using the scale developed by Thomas-Stonell and Greenberg (Drooling Severity and Frequency Scale). Individuals having a drooling severity value of 1 were included in the not drooling group (group 2) (n=27). Individuals having a drooling severity of 2, 3, 4, or 5 were included in the drooling group (group 1) (n=29). The evaluations were applied to both groups. [Results] There were significant differences between the two groups in terms of gestational age, nutrition behavior, eating abilities, head control, gagging, nutritional status (inadequate nutrition, normal nutrition, over weight-obese), and low weight. It was established that as head control increased, drooling severity diminished, and as drooling severity increased, BMI index decreased. Independence of eating ability was found to be greater in the group having better drooling control. [Conclusion] In the present study, it was determined that drooling control affected nutritional functions and that drooling control was affected by head control.Key words: Drooling, Cerebral palsy, Dysphagia     

针刺疗法和吞咽协调在改善脑性瘫痪患儿吞咽障碍中的作用

目的探讨针刺疗法和吞咽协调在改善脑性瘫痪(简称脑瘫)患儿吞咽障碍中的作用。方法将70例脑瘫患儿按随机数字表法随机分为治疗组和对照组,每组各35例。对照组在常规护理基础上,采用吞咽协调康复护理,治疗组在此基础上采用针刺疗法。比较两组患儿吞咽障碍和康复疗效的差异。结果两组患儿吞咽障碍和康复治疗总有效率均优于对照组,两组比较,均P<0.05,差异具有统计学意义。结论在实施吞咽协调康复护理基础上采用针刺疗法,可有效改善患儿吞咽障碍,从而达到改善患儿营养状况的目的,促进了患儿的康复,提高了患儿生存质量。     

Intramuscular fat in children with unilateral cerebral palsy

BackgroundMany children with cerebral palsy develop muscle contractures. The mechanisms of contracture are not well understood. We investigated the possibility that, because fat is stiffer than passive muscle, elevated intramuscular fat contributes to contracture. In this cross-sectional study, we compared the quantity and distribution of intramuscular fat in muscles from typically developing children and children with cerebral palsy who have contractures.MethodsmDixon magnetic resonance images were obtained from the legs of 20 ambulant children with unilateral spastic cerebral palsy who had ankle contractures (mean age 11 SD 3 years, 13 male, mean moderate level contracture) and 20 typically developing children (mean age 11 SD 4 years, 13 male). The images were analyzed to quantify the intramuscular fat fraction of the medial gastrocnemius muscles. The amount and distribution of intramuscular fat were compared between muscles of children with cerebral palsy and typically developing children.FindingsIn typically developing children, the medial gastrocnemius muscles had a mean intramuscular fat fraction of 4.7% (SD 1.6%). In children with cerebral palsy, the mean intramuscular fat fractions in the more- and less-affected medial gastrocnemius muscle were 11.4% (8.1%) and 6.9% (3.4%) respectively. There were small but statistically significant regional differences in the distribution of intramuscular fat. There was no evidence of a relationship between intramuscular fat fraction and severity of contracture.InterpretationChildren with cerebral palsy have higher proportions of intramuscular fat than typically developing children. There is no clear relationship between intramuscular fat fraction and dorsiflexion range of motion in children with cerebral palsy.     

Differences in coordination and timing of pre-reaching upper extremity movements may be an indicator of cerebral palsy in infants with stroke: A preliminary investigation

BackgroundNeonatal stroke is a leading cause of hemiplegic cerebral palsy that occurs around the time of birth. Infants are diagnosed with cerebral palsy when motor impairments become clinically apparent, months or years after the stroke. Tools/methods for identifying high risk or diagnosis of cerebral palsy in infancy are improving.MethodsWe measured spatial and temporal kinematics of pre-reaching upper extremity movements in 2–3 month old infants with neonatal stroke and typical development. We aimed to evaluate the feasibility of applying kinematics in this population and collect preliminary data to explore (1) if asymmetries are present in the infants with neonatal stroke, particularly those with a later diagnosis of cerebral palsy, and (2) to compare differences in the timing and coordination of their movements to infants with typical development, and infants with stroke and no cerebral palsy. Participants were 21 full-term infants, 10 with stroke (4 who later received a cerebral palsy diagnosis) age 72.1 (SD 9.3) days, and 11 typically developing, age 74.3 (SD 9.3) days.FindingsResults showed that infants with stroke and cerebral palsy demonstrated significant asymmetry in the average movement length (p = 0.0089) and hand path length (p = 0.0275) between their involved and uninvolved sides and moved less frequently (p = 0.09) and slower (p = 0.041) than infants with stroke and no cerebral palsy.InterpretationResults suggest that kinematic analysis might detect asymmetries and motor impairment indicative of hemiplegic cerebral palsy earlier than current assessments and that asymmetry in speed, length and frequency of arm movements may be early indicators. This study is preliminary, limiting interpretation of the results.     

Venomous fish stings on the European seashore

Abstract

Background: Cerebral palsy is a nonprogressive brain disorder associated with lifelong motor impairments and often with cognitive deficits, impaired communication, and impaired sensory perception. Vision deficits, in particular, occur frequently in cerebral palsy and can lead to reading difficulties. Objective: Investigate the extent to which the motor impairments in this clinical group affect patients' ability to read. Methods: An eye-tracking system was used to record the eye movements during a reading task in 31 adults diagnosed with cerebral palsy and in 10 healthy controls. Participants were asked to read out loud 1 to 5 excerpts from children's books. Results: In comparison to the healthy readers, cerebral palsy patients took longer to read the excerpts; made more saccades, fixations, and regressions; and made shorter saccades. Average fixation times were similar between the 2 groups, but the average saccade duration was significantly longer for the cerebral palsy group, as a function of the degree of severity of motor impairment. The latter was not a determinant of the level of text comprehension achieved by these patients. Conclusions: Objective measures of eye movement during a reading task can be obtained in cerebral palsy patients using eye-tracking techniques. Results suggest that cerebral palsied patients may experience difficulties in searching for words during reading.     

Fatigue in the mothers of children with cerebral palsy

Purpose: To evaluate fatigue in the mothers of children with cerebral palsy (CP), and to determine its associations with clinical parameters of CP, depression and quality of life (QoL). Method: Ninety children (50 girls and 40 boys) with spastic CP and their mothers were included. Control group comprised mothers of healthy children. Gross motor function classification system (GMFCS) was used for determining functional status. Spasticity was evaluated by using modified Ashworth scale. Fatigue symptom inventory (FSI) was used for assessing maternal fatigue, Nottingham health profile (NHP) for maternal QoL, and Beck Depression Scale (BDS) for maternal depression. Results: Mothers of children with CP scored significantly higher in all FSI subgroups (intensity of fatigue, duration of fatigue and interference with QoL), all NHP subgroups and BDS (p?p?< 0.01). No association was found between FSI and clinical parameters of children with CP including age, gender, type of CP, tonus and functional impairment (p?>?0.05). Conclusions: Our findings indicate that fatigue levels of mothers with CP children are higher than those with healthy children and associated with depression and deterioration in QoL in terms of physical, social and emotional functioning. This should be considered while designing a family centred rehabilitation programme for children with CP.

• Implications for Rehabilitation

• Caring for a child with cerebral palsy has psychological, social and financial impacts on familiesand is associated with increased levels of fatigue among mothers.

• The capacity of current programs and services needs to be strengthened to accommodate theneeds of children with CP and their mothers in order to reduce fatigue of mothers.

• New programs need to be developed to provide psychosocial support for the mothers andto reduce their fatigue as they continue to care for their children.

• Provision of assistive technology devices (particularly suitable wheelchairs) will be useful inreduction of fatigue levels of mothers.

     

What makes children with cerebral palsy vulnerable to malnutrition? Findings from the Bangladesh cerebral palsy register (BCPR)

Purpose: To assess the nutritional status and underlying risk factors for malnutrition among children with cerebral palsy in rural Bangladesh.

Materials and methods: We used data from the Bangladesh Cerebral Palsy Register; a prospective population based surveillance of children with cerebral palsy aged 0–18 years in a rural subdistrict of Bangladesh (i.e., Shahjadpur). Socio-demographic, clinical and anthropometric measurements were collected using Bangladesh Cerebral Palsy Register record form. Z scores were calculated using World Health Organization Anthro and World Health Organization AnthroPlus software.

Results: A total of 726 children with cerebral palsy were registered into the Bangladesh Cerebral Palsy Register (mean age 7.6 years, standard deviation 4.5, 38.1% female) between January 2015 and December 2016. More than two-third of children were underweight (70.0%) and stunted (73.1%). Mean z score for weight for age, height for age and weight for height were ?2.8 (standard deviation 1.8), ?3.1 (standard deviation 2.2) and ?1.2 (standard deviation 2.3) respectively. Moderate to severe undernutrition (i.e., both underweight and stunting) were significantly associated with age, monthly family income, gross motor functional classification system and neurological type of cerebral palsy.

Conclusions: The burden of undernutrition is high among children with cerebral palsy in rural Bangladesh which is augmented by both poverty and clinical severity. Enhancing clinical nutritional services for children with cerebral palsy should be a public health priority in Bangladesh.

• Implications for Rehabilitation

• Population-based surveillance data on nutritional status of children with cerebral palsy in Bangladesh indicates substantially high burden of malnutrition among children with CP in rural Bangladesh.

• Children with severe form of cerebral palsy, for example, higher Gross Motor Function Classification System (GMFCS) level, tri/quadriplegic cerebral palsy presents the highest proportion of severe malnutrition; hence, these vulnerable groups should be focused in designing nutrition intervention and rehabilitation programs.

• Disability inclusive and focused nutrition intervention programme need to be kept as priority in national nutrition policies and nutrition action plans specially in low- and middle-income countries.

• Community-based management of malnutrition has the potential to overcome this poor nutritional scenario of children with disability (i.e., cerebral palsy). The global leaders such as World Health Organization, national and international organizations should take this in account and conduct further research to develop nutritional guidelines for this vulnerable group of population.

     

Intraparotid injection of botulinum toxin A as a treatment to control sialorrhea in children with cerebral palsy

OBJECTIVE: To determine the efficacy of botulinum toxin A in the management of drooling (sialorrhea) in children and young adults with cerebral palsy. DESIGN: Twenty-one children were enrolled in an open-label, nonblinded prospective study. Subjective and objective measures were used to determine the effect of botulinum toxin A on drooling and saliva production. Subjective measures included visual scales to document the child's severity and frequency of drooling. Objective measures included the number of bibs used per day and salivary secretion. At the initial visit, subjective and objective measures established the child's baseline drooling and saliva production. Fifteen units of botulinum toxin A was injected into each parotid glans. At each fellow-up visit of telephone survey, subjective and objective measures were recorded to monitor the child's drooling and saliva production. A postinjection questionnaire evaluated overall effect and caregiver satisfaction. RESULTS: The visual analog scales and number of bibs used per day demonstrated statistically significant reduction in severity and frequency of drooling at 2 wks, 1 mo and 2 mos. Salivary production was significantly reduced at 1-mo fellow-up. Eighty-nine percent of the caregivers reported and improvement of their child's drooling after botulinum toxin A injection. Severity-nine percent of caregivers were satisfied with the treatment and would perform the treatment again. CONCLUSION: Intraparotid injections of botulinum toxin A are efficacious in decreasing severity and frequency of drooling, the number of bibs used per day, and the production of saliva in children with cerebral palsy. The injections are relatively safe and adverse effects were observed in this study.     

Cognitive and academic profiles in children with cerebral palsy: A narrative review

BackgroundConsiderable effort has recently been made to improve the accurate diagnosis of cerebral palsy (CP) in childhood and to establish early intervention aiming to improve functional outcome. Besides the visible motor impairments, cognitive abilities are frequently affected but might remain unrecognised in children with mild forms. On the other hand, some severely disabled children with presumed intellectual disabilities might demonstrate normal-range reasoning capacities. Most studies on this topic have emphasized a variety of cognitive profiles (cognitive level) related to the type of cerebral palsy and the underlying brain lesions (biological level). However, little is known at the behavioural level, namely learning skills and educational achievement.ObjectiveThis narrative review aimed to discuss cognitive and scholastic skills typically affected in children with CP.MethodsOnline literature research for studies of cerebral palsy, cognition and academic achievement, extracting all relevant articles regardless of article type.ResultsIn children with CP, intellectual disability is frequent and correlated with the degree of motor impairment and early epilepsy. Speech and language problems are prevalent in all forms of CP and might hamper everyday participation on varying levels depending on the degree of motor disability. Most children with CP have neuropsychological deficits affecting predominantly visuospatial functions, attention, and/or executive functions. These problems relate to academic performance and social participation.DiscussionAn adequate interdisciplinary follow-up of children with CP requires a sensitization of clinicians to the complex topic of cognitive and academic problems in this population and a better synergy between the medical and educational worlds.     

Explicit and implicit motor learning in children with unilateral cerebral palsy

Abstract

Objectives: The current study aimed to investigate the capacity for explicit and implicit learning in children with unilateral cerebral palsy.

Participants: Children with left and right unilateral cerebral palsy and typically developing children shuffled disks toward a target.

Design: A prism-adaptation design was implemented, consisting of pre-exposure, prism exposure, and post-exposure phases. Half of the participants were instructed about the function of the prism glasses, while the other half were not.

Measures: For each trial, the distance between the target and the shuffled disk was determined. Explicit learning was indicated by the rate of adaptation during the prism exposure phase, whereas implicit learning was indicated by the magnitude of the negative after-effect at the start of the post-exposure phase.

Results No significant effects were revealed between typically developing participants and participants with unilateral cerebral palsy. Comparison of participants with left and right unilateral cerebral palsy demonstrated that participants with right unilateral cerebral palsy had a significantly lower rate of adaptation than participants with left unilateral cerebral palsy, but only when no instructions were provided. The magnitude of the negative after-effects did not differ significantly between participants with right and left unilateral cerebral palsy.

Conclusions: The capacity for explicit motor learning is reduced among individuals with right unilateral cerebral palsy when accumulation of declarative knowledge is unguided (i.e., discovery learning). In contrast, the capacity for implicit learning appears to remain intact among individuals with left as well as right unilateral cerebral palsy.

• Implications for rehabilitation

• Implicit motor learning interventions are recommended for individuals with cerebral palsy, particularly for individuals with right unilateral cerebral palsy

• Explicit motor learning interventions for individual with cerebral palsy – if used – best consist of singular verbal instruction.

     

Functional and physiological outcomes from an exercise-based dysphagia therapy: a pilot investigation of the McNeill Dysphagia Therapy Program

Crary MA, Carnaby GD, LaGorio LA, Carvajal PJ. Functional and physiological outcomes from an exercise-based dysphagia therapy: a pilot investigation of the McNeill Dysphagia Therapy Program.ObjectiveTo investigate functional and physiological changes in swallowing performance of adults with chronic dysphagia after an exercise-based dysphagia therapy.DesignIntervention study: before-after trial with 3-month follow-up evaluation.SettingOutpatient clinic within a tertiary care academic health science center.ParticipantsAdults (N=9) with chronic (>12mo) dysphagia after unsuccessful prior therapies. Subjects were identified from among patients referred to an outpatient dysphagia clinic. Subjects had dysphagia secondary to prior treatment for head/neck cancer or from neurologic injury. All subjects demonstrated clinical and fluoroscopic evidence of oropharyngeal dysphagia. No subject withdrew during the course of this study.InterventionsAll subjects completed 3 weeks of an intensive, exercise-based dysphagia therapy. Therapy was conducted daily for 1h/d, with additional activities completed by subjects each night between therapy sessions.Main Outcome MeasuresPrimary outcomes were clinical and functional change in swallowing performance with maintenance at 3 months after intervention. Secondary, exploratory outcomes included physiological change in swallow performance measured by hyolaryngeal elevation, lingual-palatal and pharyngeal manometric pressure, and surface electromyographic amplitude.ResultsClinical and functional swallowing performances improved significantly and were maintained at the 3-month follow-up examination. Subject perspective (visual analog scale) on functional swallowing also improved. Four of 7 subjects who were initially feeding tube dependent progressed to total oral intake after 3 weeks of intervention. Physiological indices demonstrated increased swallowing effort after intervention.ConclusionsSignificant clinical and functional improvement in swallowing performance followed a time-limited (3wk) exercise-based intervention in a sample of subjects with chronic dysphagia. Physiological changes after therapy implicate improved neuromuscular functioning within the swallow mechanism.