Oral sensorimotor therapy: Assessment,efficacy and future directions

This review addresses the current state of knowledge in oral sensorimotor therapy for children with neurological impairments and ingestive problems. Comprehensive assessment of the child with dysphagia looks at the interaction of oral performance and growth. These domains include eating efficiency, oral-motor skills, oral sensory evaluation, classification of the severity of an eating problem, interaction of respiration and ingestion, aspiration, positioning for feeding, social skills assessment, careload and assessment technologies. Oral sensorimotor therapy improves eating but not drinking skills in children 3–12 years of age. Weight gain is sufficient so that children maintain their growth channel but they do not show catchup growth. Many factors thought to contribute to better ingestive performance need further study, such as jaw and lip control in association with drinking. The earliest possible identification of infants at risk for eating impairments needs to be rigorously pursued. Such an approach offers hope that the later growth deterioration now seen in children with eating impairments may be prevented. Finally, the effect of positioning and the use of eating equipment to promote self-feeding need further study.     

Tongue movements in normal 2- to 8-year-old children: extended profile of an eating assessment

In this study tongue movements of 103 normal 5-, 6-, 7-, and 8-year-old children were measured and compared. The 5-year-olds were compared with children of an earlier study and data were combined for 2- to 8-year-old children. Two different tongue positions were measured as three standard textures of food were presented: first, the position of the tongue as the food was 5 cm away from the lips, and second, the position of the tongue or other oral characteristics as the food was swallowed. For the anticipation of food a significant age-texture (p less than .001) as well as an age-sex-texture interaction was noted (p less than .035). For swallowing, significant age (p less than .0001), texture (p less than .0001), and sex-age interactions (p less than .0001) were found. Although food is anticipated in a similar fashion by both sexes, age and texture differences must be taken into account when swallowing is evaluated. A preliminary developmental curve for the two eating behaviors is presented for children 2 to 8 years old.     

Early chronic lead exposure reduces exploratory activity in young C57BL/6J mice

Research has suggested that chronic low‐level lead exposure diminishes neurocognitive function in children. Tests that are sensitive to behavioral effects at lowest levels of lead exposure are needed for the development of animal models. In this study we investigated the effects of chronic low‐level lead exposure on exploratory activity (unbaited nose poke task), exploratory ambulation (open field task) and motor coordination (Rotarod task) in pre‐adolescent mice. C57BL/6J pups were exposed to 0 ppm (controls), 30 ppm (low‐dose) or 230 ppm (high‐dose) lead acetate via dams’ drinking water administered from birth to postnatal day 28, to achieve a range of blood lead levels (BLLs) from not detectable to 14.84 µg dl^–1). At postnatal day 28, mice completed behavioral testing and were killed (n = 61). BLLs were determined by inductively coupled plasma mass spectrometry. The effects of lead exposure on behavior were tested using generalized linear mixed model analyses with BLL, sex and the interaction as fixed effects, and litter as the random effect. BLL predicted decreased exploratory activity and no threshold of effect was apparent. As BLL increased, nose pokes decreased. The C57BL/6J mouse is a useful model for examining effects of early chronic low‐level lead exposure on behavior. In the C57BL/6J mouse, the unbaited nose poke task is sensitive to the effects of early chronic low‐level lead exposure. This is the first animal study to show behavioral effects in pre‐adolescent lead‐exposed mice with BLL below 5 µg dl^–1. Copyright © 2014 John Wiley & Sons, Ltd.     

Reliability,validity and responsiveness of the cross-culturally adapted Italian version of the core outcome measures index (COMI) for the neck

Purpose

Evaluation of the psychometric properties of a cross-culturally adapted questionnaire, the Core Outcome Measurement Index for neck pain (COMI-neck).

Methods

The COMI-neck was cross-culturally adapted for the Italian language using established procedures. The following psychometric properties of the instrument were then assessed in patients with chronic neck pain undergoing rehabilitation: test–retest reliability (intraclass correlation coefficient, ICC); construct validity by comparing COMI-neck with the Neck Pain and Disability Scale, a numerical pain rating scale, and the EuroQol-Five Dimension (Pearson’s correlations); and responsiveness by means of Standardized Response Mean (SRM), unpaired t tests, and Receiver Operating Characteristics (ROC) curves.

Results

The questionnaire was completed by 103 subjects. The COMI-neck summary score displayed no relevant floor or ceiling effects. Test–retest reliability was excellent (ICC = 0.87). With one exception (symptom-specific well-being), the individual COMI items and the COMI summary score correlated to the expected extent with the scores of the reference questionnaires (r = 0.40–0.80). The mean change scores for the Italian COMI-neck differed significantly between patients with a good global outcome and those with a poor outcome (p = 0.002); SRM for the good outcome group was 1.23, and for the poor outcome group 0.40. ROC analysis revealed an area under the curve of 0.73 (95 % CI: 0.62–0.85).

Conclusions

This study provides evidence that the Italian version of the COMI-neck is a valid and responsive questionnaire in the population of patients examined. Its use is recommended for clinical and research purposes.     

Feeding Skills and Growth After One Year of Intraoral Appliance Therapy in Moderately Dysphagic Children with Cerebral Palsy

We determined changes in functional feeding skills and growth after one year of intraoral appliance therapy in dysphagic children. Twenty children, 4.2-13.1 years of age (average 8.3 +/- 0.9 years), participated in this study. Children wore the appliance daily. Phase I of treatment (6 months) aimed primarily at stabilizing the mandible and phase II aimed at facilitating ingestive skills. A control period of 6 months preceded treatment. Functional feeding skills improved significantly during phase I beyond changes seen during the control period. Further significant improvement occurred in chewing during phase II. All children significantly gained weight (kg) during the control period, as well as during the two treatment phases. This weight gain was sufficient for children to maintain their growth trajectory. There was also significant growth in height (cm). This growth spurt was characterized by marginal catch-up. Jaw stabilization was a major contributor to the significant improvement in functional feeding skills. Weight gain cannot be attributed to intervention because it occurred during the control period and was the same in magnitude through both treatment phases. However, it permitted a period of growth in stature which previously had been described only after tube feeding.     

Local/regional and systemic treatments of hepatocellular carcinoma

Screening programs for patients with cirrhosis are designed to detect hepatocellular carcinoma at an early stage when effective treatment is feasible and may provide long-term survival benefits. However, only a minority of these patients will be considered candidates for liver transplantation or surgical resection and hence, most cases will be evaluated for other medical options. While systemic therapy has never been shown to bear a relevant antitumoral activity with an impact on survival, there are several locoregional options that can achieve a high rate of objective responses (this includes complete necrosis or partial reduction in tumor burden). Percutaneous ablation by any of the available methods (ethanol injection, radiofrequency, microwave, acetic acid injection, laser) is extremely useful in patients with small solitary tumors. Results indicate that 90% of tumors < 2 cm will be completely ablated using the percutaneous approach. However, when tumor size exceeds 3 cm and/or the number of nodules is greater than 3, the rate of treatment success is significantly reduced. In patients with large/multifocal disease, the sole option that has been shown to provide treatment efficacy with moderate improvement in survival is chemoembolization. New therapeutic agents should target biological mechanisms in a tailored strategy, and the demonstration of beneficial results for patients should be obtained by large, randomized, controlled trials comparing active intervention versus no treatment.     

Lateralization of tongue movements during eating in children 2 to 5 years old

Normative data on skills of the tongue used in eating are presented. Normal children 2 to 5 years old were studied regarding their preference of placing food either on the right or left side when eating, and they were compared with age-matched Down's syndrome children. In addition, the ability to move food from the right to the left side of the mouth was studied. Normal children underwent a transition from predominantly placing food on the right side at 2 years of age to predominantly placing it on the left side at 4 years of age. Among Down's syndrome children females preferred the right side, and males preferred the left side. The ability to move food from right to left (lateralizing) undergoes a developmental progression from tilting the head to rolling, followed by slow and eventually by smooth movement from one side to the other. Only 15% of the 5-year-olds were able to move food smoothly from side to side. These data provide a baseline against which children with eating problems can be compared.     

McGill Ingestive Skills Assessment (MISA): Development and First Field Test of an Evaluation of Functional Ingestive Skills of Elderly Persons

There is a lack of reliable and valid clinical assessment tools for individuals with loss of ingestive skills. The McGill Ingestive Skills Assessment (MISA) was developed to facilitate the reliable and valid bedside assessment of elderly persons with feeding difficulties. Items were generated by a literature review and selected with the collaboration of a multidisciplinary team. The first version of the MISA comprised 190 items in 7 scales, covering the domains of medical history, mealtime environment, physical characteristics of the patient, food textures consumed, solid ingestion, liquid ingestion, and behaviors related to self-feeding. The first field test for item selection included 50 individuals, aged 60 years and older, living in the community, supervised housing, and long-term care centers. After field testing, 134 items were eliminated due to poor face validity, redundancy, or poor psychometric performance. The remaining 56 items were provided with 4 response categories and were reorganized into 5 scales. The revised version was field tested to determine its preliminary psychometric properties on 33 individuals, 60 years of age and older, residing in a long-term care center. Six items were eliminated due to redundancy after the second field test. Analyses of the revised version resulted in the elimination of another 6 items that were redundant or that demonstrated poor reliability. Internal consistency of all scales is 0.86 and interrater agreement is 0.92. These analyses suggest that the psychometric properties of the MISA are adequate for diagnosis and treatment planning. This supports its readiness for clinical use following further reliability and validity testing with a larger sample Presented in part to the Dysphagia Research Society, Toronto, Ontario, Canada, October 1997, and Burlington, VT, October 1999, and to the American Geriatrics Society, Nashville TN, May 2000.     

Superior mesenteric artery (Wilkie’s) syndrome as a result of cardiac cachexia

Superior mesenteric artery (SMA) syndrome is a rare acquired disorder in which acute angulation of SMA causes compression of the third part of the duodenum between the SMA and the aorta, leading to obstruction. Loss of fatty tissue as a result of a variety of debilitating conditions is believed to be the etiologic factor causing the acute angulation. We report a case of an 86-year-old man with prolonged congestive heart failure and aortic stenosis in which SMA syndrome developed as a result of cardiac cachexia. Because of poor functional status and comorbidities, he was not a suitable candidate for decompressive surgery. Conservative treatment using a gastrostomy tube with jejunal extension led to improvement in nutritional status and resolution of symptoms. The authors have no conflicts of interest to declare for this article or this research.     

Chewing cycles in 4- and 5-year-old normal children: an index of eating efficacy

Eating movements in the preschool child undergo change between the ages of 2 and 5 years. There is a lack of objective clinical data from normal children against which eating movements of feeding-impaired children can be compared. In this study, chewing movements were measured to complement tongue movements described in an earlier study. The movements were monitored in 40 children: 20 were four years old and 20 were five years old. Each group had ten boys and ten girls. Chewing movements were measured by time (sec), number of cycles, and a time/cycle ratio. A chewing cycle was defined as an upward and downward movement of the chin. Total time from the moment food was placed in the mouth until the final swallow occurred was divided by the number of cycles counted for the same period. Age and sex did not affect time, cycles, or the time/cycle ratio. However, the measures were strongly affected by the type of food eaten. These findings suggest that the texture of food strongly influences both the number of chewing cycles performed and the time used for chewing. The occupational therapist administering eating evaluations to children should carefully choose the foods offered for initial evaluations and use the same food consistently during re-evaluations.