Center on Disability and Community Inclusion
University of Vermont
Mann Hall – 3rd floor
208 Colchester Ave.,
Burlington VT 05405-1757
Evidence-based Journal Club
Locations
Waterbury
Williston
St Albans
White River Junction
Randolph
Castleton
December 3, 2008 (4:00 – 6:00 pm)
Expected Participants
Sandra Cameron, OT
Mary Ellen Seaver-Reid
Sarah Pashby, PT
Liliane Savard, DPT
Lauren Briere
Marie-Christine Potvin, OT
Deanna Wilcox, OT
Charlene Mongeon, PT
Peggy Owen
Mary Daniels
Jean Beatson, EdD, RN
Mackenzie Dumar Sillick, SLP
Tracey Burke OT
Dot Aitken
Linda Kogut, OT
Nancy Baker, SLP
Michele Barnier
Deb O’Rouke
Karen Downey
Susan Willis
Bailee Layn
Steve Contompasis
Brooke Milo, COTA
Amanda Harris
Chris Knippenberg
Beth Pastor, PT
Amy Thacker, SLP
Janet Correia
Denise Mitchell
Tricia Parmelee
Phoebe Chestna
Instructions to Participants:
1) Please sign-in AND sign-out on the TRIPSCY sign-in sheet. This is critical for OTs who want to
report this activity for continuing education credits.
2) Handouts were sent to you by email.
3) Please assign one person at each site who will collect all the material at the end (i.e., sign-in sheets,
completed surveys, etc.) and give it to the VIT technician.
Thank you and see you all on the air,
Marie-Christine Potvin
Center of Disability and Community Inclusion/UVM
Mann Hall – 3rd floor
208 Colchester Ave.
Burlington VT 05405-1757
Evidence-based Journal Club
December 3, 2008
Page 1
Roles
Facilitator: Deanna Wilcox
Recorder: Marie-Christine Potvin
Time keeper:
Keeper of the rudder:
Processor:
Wellness provider:
Agenda
4:00
Welcome, Check in with all sites, reminder to sign-in, microphone instructions, overview of the
agenda and general orientation to the handout (Deanna)
4:10
Today’s topic and how the articles were selected (Deanna)
4:20
Article reviews summary (15 min. each with questions)
- Clawsom et al. 2007
Reviewer: Linda Kogut
- Gisel et al. 1996
Reviewer: Paul Woodruff
- Gisel 1994
Reviewer: Deanna Wilcox
- Gisel 1996
Reviewer: Deanna Wilcox
Co-reviewer: Deanna Wilcox
Co-reviewer: Deanna Wilcox
5:20
Discussion (Deanna)
5:45
Next meeting (Deanna)
Topic:
Date: March 31st, 2009 (4:00-6:00 PM); January meeting cancelled
5:55
End --- Remember to sign-out!!!
Literature Search
Topic: Outcomes of oral-motor strategies or interventions for children with cerebral palsy and dysphagia.
PICO Question: In children with cerebral palsy and dysphagia what is the efficacy of oral-motor
strategies or interventions on improving oral feeding?
Resources searched:
1. Databases reviewed Cochrane Library (1980-2008)
 Ovid- CINAHL (1982-present), MEDLINE (1980-present)
 PsycInfo (earliest-2009)
 Web of Science (1982-2008)
 ERIC (1980-2009)
 LLBA- Linguistics and Language Behavior Abstracts (1980-2009)
 PubMED single citation match/related article search (this was only done for 1-2 articles)
2. Websites searched AACPDM
 CANCHILD
3. Journals- hand-search onlineEvidence-based Journal Club
December 3, 2008
Page 2


American Journal of Occupational Therapy (2000-2008)
Dysphagia (most recent 10 years)
4. Review reference lists of all articles
Search Terms:
Exploratory searches were done using the terms: (feed* or eat*) and child* and oral-motor - to get a sense
of the literature available and the keywords and subject headings used to classify the literature. After
meeting with the Dana Medical Library librarian, re-ran the database searches using subject headings.
Subject headings were specific to each database used. Here are some combinations:
 cerebral palsy and [(eating or eating disorders or eating disorders management or self-care: eating)
or (deglutition or deglutition disorders)]
 cerebral palsy and (ingestion or (eating behavior) or dysphagia)
 cerebral palsy and [(deglutition disorder or deglutition) or (eating or feeding and eating disorders
of childhood or eating disorders)]
#
1
2
Citation:
Ottenbacher, K.,
Scoggins, A, &
Wayland, J.
(1981).
Ottenbacher, K.,
Bundy, A., &
Short, M.A.
(1983).
Clawson, E.,
Kuchinski, K.S.,
& Bach, R.
(2007).
N=:
20
8
Ages:
5-21.6
years
Diagnosis:
Severely and
profoundly
intellectually
disabled with
neuromotor
disorders (18 with
CP)
Persons who are
severely and
profoundly
disabled
spastic diplegic
cerebral palsy
Method:
Pre-test/posttest control
group design
Tx.:
9 week program of oral
therapy designed to
normalize oral-motor
functions and reduce
pathological oral
reflexes.
Review
2.5 –
10
years
moderately
dysphagic children
with cerebral palsy
quasiexperimental
design with
repeated
measures.
Therapies based on
neuro-developmental
and sensorimotor
facilitation procedures
Intensive day tx.
program with oralmotor exercises,
behavioral
interventions, and
parental education to
increase oral feeding.
Oral sensorimotor tx.
4.313.3
years
moderately eating- RCT
impaired child with (10-20 weeks)
cerebral palsy
moderately eating- RCT
18
mos. –
4.7
years
3
4
Gisel, E.G.,
ApplegateFerrante, T.,
Benson, J., &
Bosma, J.F.
(1996).
Gisel, E.G.
(1994).
27
35
5
Gisel, E.G.
35
Evidence-based Journal Club
December 3, 2008
Single subject
AB (A??)
(5.8 weeks tx.,
but followed
over 3 years)
Oral sensorimotor tx.
Oral sensorimotor tx.
Page 3
6
7
8
9
(1996).
Gisel, E.G.,
ApplegateFerrante, T.,
Benson, J.E.,
&Bosma, J.F.
(1995).
Helfrich-Miller,
K.R., Rector,
K.L., Straka, J.A.
(1986).
Rogers, B. (2004)
27
6
10 Davies, F. (2003)
Mean
age
5.1
impaired child with
cerebral palsy
moderately
dysphagic children
with cerebral palsy
(10-20 weeks)
quasiexperimental
design with
repeated
measures.
Oral sensorimotor
treatment
Cerebral palsy with
profound
intellectual
disabilities
Cerebral palsy
Unclear with
abstract only.
(18-months
study)
Review
Dietary modification,
oral-motor treatment,
thermal stimulation.
Cerebral Palsy
Review
Oral feeding methods
and gastrostomy tube
feedings
Oromotor treatment
This process resulted in the following related articles:
1. Ottenbacher, K., Scoggins, A, & Wayland, J. (1981). The effectiveness of a program of oral sensorymotor therapy with the severely and profoundly developmentally disabled. The Occupational Therapy
Journal of Research, 1: 147-160.
2. Ottenbacher, K., Bundy, A., & Short, M.A. (1983). The development and treatment of oral-motor
dysfunction: A review of clinical research. Physical & Occupational Therapy in Pediatrcis, 3(2): 113.
3. Clawson, E., Kuchinski, K.S., & Bach, R. (2007). Use of behavioral interventions and parent
education to address feeding difficulties in young children with spastic diplegic cerebral palsy.
NeuroRehabilitation, 22, pp. 397-406.
4. Gisel, E.G., Applegate-Ferrante, T., Benson, J., & Bosma, J.F. (1996). Oral-motor skills following
sensorimotor therapy in two groups of moderately dysphagic children with cerebral palsy: Aspiration
vs nonaspriation. Dysphagia, 11, pp. 59-71.
5. Gisel, E.G. (1994). Oral-motor skills following sensorimotor intervention in the moderately eatingimpaired child with cerebral palsy. Dysphagia, 9:180-192.
6. Gisel, E.G. (1996). Effect of oral sensorimotor treatment on measures of growth and efficiency of
eating in the moderately eating-impaired child with cerebral palsy. Dysphagia, 11: 48-58.
7. Gisel, E.G., Applegate-Ferrante, T., Benson, J.E., &Bosma, J.F. (1995). Effect of oral sensorimotor
treatment on measures of growth, eating efficiency and aspiration in the dysphagic child with cerebral
palsy. Developmental medicine and child neurology, 37(6):528-543.
8. Helfrich-Miller, K.R., Rector, K.L., Straka, J.A. (1986). Dysphagia: Its treatment in the profoundly
retarded patient with cerebral palsy. Archives of Physical Medicine & Rehabilitation, 67(8):520-525.
9. Rogers, B. (2004). Feeding method and health outcomes of children with cerebral palsy. Journal of
Pediatrics, 145:S28-S32.
10. Davies, F. (2003). Does the end justify the means? A critique of oromotor treatment in children with
cerebral palsy. Asia Pacific Journal of Speech, Language, and Hearing, 8(2): 146-152.
ARTICLES REVIEWED:
Article 1
Evidence-based Journal Club
December 3, 2008
Page 4
Reference: Clawson, E., Kuchinski, K.S., & Bach, R. (2007).
Summary: The intent of this study was to assess the effectiveness of an intensive day treatment program
using oral stimulation and behavioral interventions, including parent training and involvement to increase
oral feeding of children with spastic diplegia cerebral palsy (SDCP). The children were referred to the
program by their pediatricians. The interdisciplinary team at the day treatment program included a
pediatric gastroenterologist, nurse practitioner, behavioral psychologist, registered dietician, OT, SLP,
feeding and diet technicians, nurses, a licensed social worker and a case manager. A before-and-after
design was used with an eight subject sample with a median age of 2.8 years. Length of stay in the
program was 29 days. Baseline anthropometric data was collected. Parent-therapist teams collaborated in
the following areas: seating/positioning, training, oral exercises, behavioral implementation and feedings.
The outcome measures were: anthropometric data, nutrition data, child feeding measures and caregiver
feeding behaviors. The Beckman Oral Motor Assessment was used to determine the child’s functional
skill level. Twenty to thirty minutes of Beckman oral-motor exercises were used prior to meals 4 times
per day. Behavioral interventions were implemented as well. Parents were trained in food preparation,
calorie boosting and feeding techniques. Parent progression through the program was based on their
achievement of accomplishing at least 80% competence at each level of training in instructions, prompts,
and consequences during feedings. The therapist was the primary feeder until appropriately the last 2
weeks of the program. Follow-up appointments at 1, 4, 7, and 12 months following discharge from the
program included documentation of anthropometric data, nutritional and behavioral counseling, calorie
counts and tube feeding adjustments. Data was analyzed using paired sample t-tests to compare
significant changes in dependent variables from admission to discharge, but neither p-values nor statistical
significance were reported. Improvements were noted in the following categories: anthropometric data,
ability to open mouth for food, timeliness of managing food, behavior, endurance for longer meal time,
volume of food, g-tube fed children required less supplements and caregivers increased their ability to
feed their children. Limitations of the study include: a small sample size, lack of reporting statistical
significance, intervention specifics were unclear, and some of the outcome measures were not reliable and
valid. The authors concluded that their study showed sustained improvements originating from intensive
treatment for oral dysphagia, oral aversion and feeding difficulties. Intensive oral-motor interventions
combined with behavioral strategies and positioning during feeding improved upon all variables.
Additional research with a focus on parental impact was recommended. Biological and behavioral aspects
of feeding disorders are mutually interactive.
Review: see other handout
Article 2
Reference: Gisel, E.G., Applegate-Ferrante, T., Benson, J., & Bosma, J.F. (1996).
Summary: This study looked at the effects of oral sensorimotor therapy on oral-motor skills and
measures of growth in children with CP and moderate eating impairment. The children were placed into 2
groups- Aspirtion/Nonaspiration- depending on results of videofluorosopy. The study was 20 weeks long
- 10 weeks for control, 10 weeks for interventions. Outcome measures were taken at the beginning, at
week 10 and at week 20. The authors looked at weight gain, skinfold thickness and feeding skills as
assessed with the FFAm (Functional Feeding Assessment, a modified subtest of the Multidisciplinary
Feeding Profile by Kenny et al.). The oral motor therapy was provided in the school, Monday through
Friday for 5- 7 minutes by a “feeder”. The “feeder” was an assistant or therapist trained in the oral motor
program individualized to the child’s needs. The results of the study were an improvement in some
Evidence-based Journal Club
December 3, 2008
Page 5
feeding skills: spoon feeding, chewing and swallowing, but not in drinking skills. The A group had
significantly poorer oral-motor skills following 10 weeks of treatment than the NA group, with the
exceptions of normal cup drinking, clearing and drooling, where they still had poorer skills, but not a
statistically significant difference. There was some change noted in skin fold thicknesses which the
authors measured as an indicator of energy reserves. The children in the Aspiration group had thinner
skin folds to start with. Both groups showed improvement. There were not any significant changes in
weight, the children maintained their weight-age percentile, but did not show any catch-up growth.
Review: see other handout
Article 3
Reference: Gisel, E.G. (1994).
Summary: The purpose of this study was to determine the efficacy of oral sensorimotor treatment in
children with cerebral palsy and moderate eating impairment and to examine the effects of treatment on
oral-motor skills and measures of growth (weight and skinfold thickness). Thirty-five children were
assigned randomly (randomization not described) to one of three groups (A, B, or C). Treatment lasted
for 20 weeks, but Group C acted as a control group for 10 weeks. From weeks 0-10, Group C followed
the school routine in regard to feeding (not described) and from weeks 10-20, they received the same
treatment as Group A (oral sensorimotor treatment). Group B received chewing-only treatment. There
were 19 boys and 16 girls ranging in age from 4.3 to 13.3 years with CP and moderate to severe motor
impairment who were selected from 3 special schools in Montreal over 2 years. The weight of the
children was at or above the 5th percentile for age and skinfold measures (triceps, subscapular) were at or
below the 35th percentile. Children had to be able to eat a standard solid texture within 1 SD and a puree
at or below 2 SD of established time norms [which were established empirically and are now used for the
classification of the severity of eating impairments (Alphonce-Schweizer and Gisel, unpublished data at
the time of this article)]. Treatment for all three groups occurred 5-7 minutes per day, Monday through
Friday prior to lunch at school. The treatment was individualized according to each child’s needs and
abilities. The texture of at least one lunch food was increased and made more resistive over time as well.
Sensorimotor treatment emphasized tongue lateralization, lip control, and vigor of chewing. Treatment
was administered by assistants instructed (in manner and time of tx.) by the author or research assistant.
Outcome measures included: a scale to measure weight, skinfold calipers to measure skinfold thicknesses
(or energy reserves), and the Modified Functional Feeding Assessment subtest (FFAm) of the Multiple
Feeding Profile (Kenny et al.) to measure functional feeding skills. All 13 functional feeding skills
measured by the FFAm showed improvement after 20 weeks for the entire sample. There weren’t any
significant between-group differences on the FFAm. There was significant improvement for: Group A in
normal spoon feeding after 20 weeks; Group B in normal chewing at week 10; and for Group C in normal
chewing at 20 weeks. Group C also had a marginally nonsignificant improvement in abnormal spoon
feeding at 20 weeks (p< 0.057). The data for weight measures suggest that children maintained their
weight-age percentile ranking, but had no catch-up growth. All groups had improved subscapular
skinfold measures at 10 and 20 weeks. The author concluded that limited improvement can be made in
spoon feeding, biting, and chewing (but not drinking) over 10 -20 weeks using sensorimotor treatment or
chewing-only treatment using low intensity treatment (5-7 min. 1x/day). Although there were no catch-up
gains in weight, weight was maintained. This is clinically meaningful because this method could be
beneficial when trying to help children with moderate eating-impairment initially improve oral-motor
skills for oral intake, during periods of recovery from illness, and/or when attempting to supplement oral
Evidence-based Journal Club
December 3, 2008
Page 6
intake with calorically denser foods requiring increased oral-motor skill. Three of the 4 statistically
significant findings occurred after 10 weeks and not many more after another 10 weeks of treatment. The
significant improvements for Group C were during their 10 weeks treatment phase. The main limitations
of the study include: that risks were taken with the modifications to the FFA therefore the true reliability
and validity, of this measure, are unknown; some aspects of the study are not well described yet there is
so much information in this article that it is somewhat difficult to follow; more p-values could have been
calculated to make more of the information easier to interpret for clinical meaningfulness, etc.
Review: see other handout
Article 4
Reference: Gisel, E.G. (1996).
Summary: The purpose of this study was to examine the efficacy of oral sensorimotor therapy in a group
of children with cerebral palsy and with moderately impaired eating who were all marginal oral feeders.
This study is an extension of the 1994 article reviewed by Dr. Gisel. Therefore the study design,
including the population and treatment are the same as that study. The outcomes being measured were
different for this article. Outcome measures included: a scale to measure weight, a modified version of
the Functional Feeding Assessment subtest (FFAm) of the Multiple Feeding Profile (Kenny et al.), and
chewing, clearing, and meal length were all timed. There were no statistically significant differences
between groups for duration of meals, although both Groups A and B tended to decrease their eating time.
Group A improved in their time taken to eat a solid texture and Group B in viscous textures No significant
differences were found in clearing time (time between first and last swallow (following a bite) or
termination of mandibular movement for 2 seconds) at week 10 or 20 as a whole or between groups.
There was no significant change in participants’ ability to eat more advanced textures, however all groups
showed improvement after 20 weeks. Weight changes were slightly above the expected averages for
typically developing children of 6-8 years, however there was no catch-up growth. Since there was such a
large variation within groups according to progress, the total sample was divided into two groups based
on whether they had 8% weight gain during 1st and 2nd treatment phases. Those who gained the most
weight had a slightly more favorable status (i.e., better treatment compliance, less frequent illness, less
intellectual disability, greater ability to ambulate with or without a device) than the others (except in
spoon feeding). The author concluded that oral sensorimotor treatment and chewing-only exercises do
not produce catch-up growth in children with CP and moderate eating-impairment. All groups essentially
only maintained weight percentile line, but perhaps children given oral sensorimotor treatment did best
with weight following treatment, provided they stayed healthy. Catch-up growth seems to occur over a
short period of time in children who are provided with sufficient calories so a longer tx. period probably
wouldn’t improve weight gain. Remedial measures (e.g., oral sensorimotor therapy, increased meal times,
more frequent feedings) probably don’t keep pace with the growth demands of these children in the
teenage years, thus caloric supplementation is needed during growth spurts. Illness of children, degree of
intellectual disability, and ambulatory status may influence a child’s response to treatment. Children with
moderate eating-impairments may benefit from oral sensorimotor treatment, but these factors may all
contribute to the outcomes. Two of the main limitations of this study include: division of sample into 3
groups made for small sample per group which may have affected the power for this study and there were
risks taken with the modification of the FFA making the true reliability and validity of this measure
unknown.
Review: see other handout
Evidence-based Journal Club
December 3, 2008
Page 7
Evidence-based Journal Club
Questions to Guide Clinical Implications Discussion
EBM Efficacy Criteria: (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000)
1a
Systematic reviews (with homogeneity) of randomized controlled trials
1b
Individual randomized controlled trials (with narrow confidence interval)
1c
All or none randomized controlled trials
2a
Systematic reviews (with homogeneity) of cohort studies
2b
Individual cohort study or low quality randomized controlled trials
2c
'Outcomes' Research; ecological studies
3a
Systematic review (with homogeneity) of case-control studies
3b
Individual case-control study
4
Case-series (and poor quality cohort and poor quality case-control studies)
5
Expert opinion
1. Are the results of the studies reliable and valid (quality of studies)? Explain?
2. Using the efficacy criteria above, what is the level of evidence of the studies reviewed today as a
group? Are there additional studies in the literature (not reviewed today) that may enhance the level of
evidence?
3. Considering the quality of the studies and the level of evidence, what do the studies’ results mean for
your clinical practice? What may you do differently in your practice with this new information (think of
assessment, intervention, education, data collection, rational, etc.)? What information could you share
with parents and other team members?
4. What additional information do you need about this topic to enhance clinical practice/decision making?
For example: additional journal club topic? Data collected at your agency? Suggestions for future
research? How will you obtain this additional information?
Information Needed:
How and by whom?
5. Combining the evidence of these studies and the discussion about clinical practice implications, what is
the take home message (2 sentences)?
Evidence-based Journal Club
December 3, 2008
Page 8