Jeri L. Miller

Emergence of oropharyngeal, laryngeal and swallowing activity in the developing fetal upper aerodigestive tract: an ultrasound evaluation

The developing fetal upper aerodigestive system provides the structural support for respiratory and ingestive functions necessary to sustain life at birth. This study investigated prenatal development of upper aerodigestive anatomy and the association of emerging functions as predictors of postnatal feeding skills. Biometric measures of oral, lingual, pharyngeal and laryngeal structures were obtained in fetuses 15-38 weeks gestational age using a four-plane sonographic technique. Accompanying ingestive behaviors were tallied across development. The data from 62 healthy controls were compared to seven cases at risk for postnatal feeding and swallowing dysfunction (Type II Arnold Chiari Malformation, trisomy 18, polyhydramnios, intrauterine growth restriction, Brachmann-de Lange Syndrome). Significant (p<0.001) linear regressions occurred in pharyngeal and lingual growth across gestation while ingestive behavior such as suckling emerged in a sequence of basic to complex movement patterns. Jaw and lip movements progressed from simple mouth opening to repetitive open-close movements important for postnatal suckling. Lingual movements increased in complexity from simple forward thrusting and cupping to anterior-posterior motions necessary for successful suckling at term. Laryngeal movements varied from shallow flutter-like movements along the lumen to more complex and complete adduction-abduction patterns. Fetal swallowing primarily occurred in the presence of concomitant oral-facial stimulatory activity. Significant variations (p<0.01) in the form and function of the ingestive system occurred in comparisons of gestational age-matched controls to at-risk cases. We postulate that prenatal developmental indices of emerging aerodigestive skills may guide postnatal decisions for feeding readiness and, ultimately, advance the care of the premature, medically fragile neonate.

Palliative and End of Life Care Research: Embracing New Opportunities

The past two decades have witnessed dramatic advances in palliative and end-of-life care research with increased understanding of the burden of life-limiting diseases on patients, families, clinicians, and our healthcare system; and researchers have documented palliative care interventions that improve patient and family outcomes and reduce the costs of care (Detering, Hancock, Reade, & Silvester, 2010). These advances have led to a new era of palliative and end-of-life care research and practice with widespread recognition of its accomplishments and successes. Consequently, we now have an important opportunity to reassess our recent successes and challenges and to identify the goals and benchmarks that will ensure ongoing robust advances in this now-recognized and critical scientific area. High-quality palliative and end-of-life care will be best informed by methodologically strong research efforts that generate a body of evidence with the capacity to support and direct care and effect changes in practice. It is in this context that the National Institute of Nursing Research conceptualized and led a Summit titled The Science of Compassion: Future Directions in End-of-Life and Palliative Care Research in August, 2011. In this summary article, we present brief overviews of the six articles chosen for this Special Issue of Nursing Outlook, examine their key conclusions, articulate gaps and needs, and discuss next steps in palliative and end-of-life care research through the lens of these six topics.

Sex differences in prenatal oral‐motor function and development

The aim of this study was to investigate sex-related differences in the prenatal development of early oral, lingual, pharyngeal, and laryngeal motor activities. Sonographic images of oral-upper airway regions were observed in 85 healthy fetuses (43 males, 42 females; mean gestational age 24wks 3d [SD 0.69]; range 15-38wks). Biometric data on morphologic development and associated motor patterns were compared across second and third trimesters. Results showed that while males and females demonstrated statistically similar patterns of general physical growth (p>0.05), significant differences in development of specific lingual and pharyngeal structures were present (p<0.05). Significant differences were found for laryngeal and pharyngeal motor activity, and oral-lingual movements (p<0.05). Complex oral-motor and upper airway skills emerged earlier in females, suggesting a sex-specific trajectory of motor development. It was concluded that differential patterns of prenatal motor development may be important in defining sex-specific indices of oral skill maturation.

Ultrasound Imaging and Swallowing

Ultrasound technology has advanced substantially, providing clinicians and researchers with vastly expanded noninvasive opportunities to study the dynamics of the oral pharyngeal system and the muscles and other soft tissues of the oropharynx during swallowing. In the current climate of cost containment and efficiency, ultrasound imaging presents a viable alternative to videofluorography to examine the oropharyngeal swallow. Because ultrasound imaging is uniquely suited for investigating soft tissue structures, it is used to view the abdomen, fetus, heart, bladder, genitalia, breast, and to visualize tumors and masses throughout the body (1–3). Ultrasound can be used to identify normal and abnormal oropharyngeal tissues such as the thyroid and salivary glands, tongue, palate, and floor of the mouth in various diseases, infections, and genetic conditions (4,5). Because of its inherent advantages (Table 8.1), ultrasound has been successfully adapted for viewing the oral cavity during swallowing (6–9). Real-time ultrasound is totally noninvasive, dynamic, and has no known bioeffects and minimal risk to the patient. Studies can therefore be performed repeatedly or for extended periods of time without risk of future tissue change from effects of long-term radiation. This property is especially relevant when one is studying infants and children who are at greater risk than adults for showing the cumulative effects of ionizing radiation. The air interface at the surface of the tongue is a nearly perfect reflector of sound, thus clearly displaying the lingual musculature and vessels both at rest and during oral motion. Ultrasound imaging is ideally suited to identifying the various soft tissues that compose the upper aerodigestive tract. In addition, the transduction properties of sound waves allow these soft tissues to be distinguished from ingested fluids, semisolids, and solid materials. Since no contrast material is needed to visualize the oropharynx and the bolus during swallowing, any type of food commonly ingested by the patient can be used during a study. The ultrasound examination is conducted with the adult or child patient seated in a comfortable position, while an infant is held on the mother’s lap. All ultrasound systems are portable, have built-in video systems, online computerized image processing and measurement programs, a computer keyboard, display screen, and hard copy printout capacity. Ultrasound is easy to use and provides reliable diagnostic information. Because of these advantages, ultrasound technology is well suited to evaluate individuals of any age from infancy to senescence, and any neurological, systemic, genetic, traumatic, developmental, or progressive condition that affects oral physiology.

Brief assessment of motor function: content validity and reliability of the oral motor scales.

Sonies BC, Cintas HL, Parks R, Miller J, Caggiano C, Gottshall SG, Gerber L: Brief assessment of motor function: Content validity and reliability of the oral motor scales. Objective:The Brief Assessment of Motor Function consists of five 0- to 10-point hierarchical scales designed for rapid assessment of gross, fine, and oral motor skills. We describe the development and evaluation of the two Brief Assessment of Motor Function Oral Motor Scales: Oral Motor Articulation and Oral Motor Deglutition. Design:This validation study employed an expert panel of 28 speech-language pathologists, who rated the Brief Assessment of Motor Function Oral Motor Scales items on a scale from 1 to 4 (disagree to agree) to establish content validity. For reliability, oral motor performances of 18 participants (6 mos–20 yrs) were videotaped to represent a wide range of articulation and deglutition capabilities. Four speech-language pathologists, and 1 undergraduate and 10 graduate speech-language pathology students rated the participants’ taped samples using the Brief Assessment of Motor Function Oral Motor Scales. Results:All items on the content validity questionnaire had average agreement scores that exceeded criteria, except two, which were not clearly worded; these were clarified. Interrater and intrarater reliability values were 0.997 and 0.986 for the Oral Motor Articulation Scale and 0.977 and 0.997 for the Oral Motor Deglutition Scale. Conclusions:Expert feedback and reliability procedures suggest that the Brief Assessment of Motor Function Oral Motor Articulation and Deglutition Scales represent the content that they are designed to assess and are reliable for rapid assessment of oral motor skills.

The influence of ankle joint movement on knee joint kinesthesia at various movement velocities

The purpose of this study was to determine if gastrocnemius elongation or shortening and direction and velocity of knee movement influenced knee kinesthesia. Healthy volunteers sat with their knee flexed (20°) and was then passively rotated (flexion or extension) at three velocities (0.5, 2, or 10°/s) while the ankle was either fixed or rotated (dorsiflexed or plantar flexed at 0.17, 0.65, or 3.3°/s) creating gastrocnemius elongation or shortening. Subjects activated a thumb switch, stopping motion once they detected onset and direction of the motion. Detection of passive movement sense (DPMS) was the angular movement before activation of a thumb‐switch. Significant differences (P=0.003) in the rate of change in DPMS across a variety of movement velocities was observed but shortening or elongation of the gastrocnemius did not affect DPMS. Gastrocnemius elongation/shortening did not affect knee DPMS, simple reaction time plays an important role in testing kinesthesia especially at faster movements. While feedback from the gastrocnemius muscle plays a limited role in healthy subjects, differences in testing velocities may incorporate higher levels of central nervous system processing. Clinical measures of kinesthesia can be affected by both movement direction and movement velocity that are speed dependent.