Voveran

Mike Zevitz, M.D.

• Assistant Professor
• Chicago Medical School
• Chicago, IL

In her paper muscle relaxant powder discount voveran 50mg overnight delivery, published in 1981 muscle relaxant 503 buy voveran without a prescription, she described 34 cases of children and adults with autism muscle relaxant rub buy on line voveran, ranging in age from 5 to 35 years 2410 muscle relaxant buy voveran 50 mg with mastercard, whose profile of abilities had a greater resemblance to the descriptions of Asperger than Kanner muscle relaxant glaucoma cheap 50mg voveran amex, and did not easily match the diagnostic criteria for autism that were being used by academics and clini cians at the time muscle relaxant neck generic voveran 50mg online. Although the original descriptions of Asperger were extremely detailed, he did not provide clear diagnostic criteria. One of the results of the discussions and papers was the publication of the first diagnostic criteria in 1989, revised in 1991 (Gillberg 1991; Gillberg and Gillberg 1989). Despite subsequent criteria being published in the two principal diag nostic manuals, and by child psychiatrist Peter Szatmari and colleagues from Canada (Szatmari, Bremner and Nagy 1989b), the criteria of Christopher Gillberg, who is based in Sweden and London, remain those that most closely resemble the original descriptions of Asperger. Thus, these are the criteria of first choice for me and many experienced clinicians. When a new syndrome is confirmed, there is a search of the international clinical lit erature to determine whether another author has described the same profile of abilities. Hans Asperger died in 1980 and was unable to comment on the interpretation of his seminal study by English-speaking psychologists and psychiatrists. It was only relatively recently, in 1991, that his original paper on autistic personality disorder was finally translated into English by Uta Frith (Asperger [1944] 1991). We currently have eight screening questionnaires that can be used with children, and six that can be used with adults. An experienced clinician needs to conduct an assessment of the domains of social reasoning, the communication of emotions, language and cognitive abilities, interests, and movement and coordination skills, as well as examine aspects of sensory perception and self-care skills. A clinician may suspect a positive diagnosis within a matter of minutes, but the full diagnostic assessment will need to be conducted to confirm the initial clinical impression. The full diagnostic assessment can take an hour or more depending on the number and depth of the assess ments of specific abilities. More experienced clinicians can significantly shorten the duration of the diagnostic assessment. Subsequent chapters will include some of the diagnostic assessment procedures that I use to examine specific abilities and behaviour. For example, the child may have achieved prizes and certificates for his or her knowl edge regarding a special interest, or demonstrated academic skills by winning a mathe matics or art competition. Parents can be asked for the endearing personality qualities of their son or daughter, for example being kind, having a strong sense of social justice, and caring for animals. Qualitative impairment in social interaction, as manifested by at least two of the following: 1. Restricted repetitive and stereotyped patterns of behaviour, interests, and activities, as manifested by at least one of the following: 1. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behaviour (other than in social interaction), and curiosity about the environment in childhood. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia. Diane Twachtman-Cullen (1998), a speech/language pathologist with considerable experience of autism spectrum disorders, has criticized this exclusion criterion on the grounds that the term clinically significant is neither scientific nor precise and left to the judgement of clinicians without an operational definition. Research has now been conducted on whether delayed language in children with autism can accurately predict later clinical symptoms. The focus during the diagnostic assessment should be on current language use (the pragmatic aspects of language) rather than the history of language development. This can range from help with problems with dexterity affecting activities such as using cutlery, to reminders regarding personal hygiene and dress sense, and encouragement with planning and time-management skills. Clinicians have also recognized significant problems with adaptive behaviour, especially with regard to anger management, anxiety and depression (Attwood 2003a). The criteria also exclude refer ence to motor clumsiness, which was described by Asperger and has been substantiated in the research literature (Green et al. It is important to recognize that the diagnostic criteria are still a work in progress. The results of the research have not established a distinct and consistent profile for each group. However, other research examining diagnos tic differentiation using neuropsychological testing has not identified a distinct profile that discriminates between the two groups (Manjiviona and Prior 1999; Miller and Ozonoff 2000; Ozonoff, South and Miller 2000). Some scores may be within the normal range or even superior range, but other scores, within the same profile, may be in the mildly retarded range. As a clinician, I do not think that academics should try to force a dichotomy when the profiles of social and behavioural abilities are so similar and the treatment is the same. According to the Gillberg criteria, the prevalence rate is between 36 and 48 per 10, 000 children, or between 1 in 280 or 210 children (Ehlers and Gillberg 1993; Kadesjo, Gillberg and Hagberg 1999). Prev alence figures indicate how many individuals have the condition at a specific point in time, while incidence is the number of new cases occuring in a specified time period, such as one year. A recent analysis of over 1000 diagnostic assessments over 12 years established a ratio of males to females of four to one. One of the coping mecha nisms is to learn how to act in a social setting, as described by Liane Holliday Willey in her autobiography, Pretending to be Normal (Willey 1999). The clinician perceives someone who appears able to develop a reciprocal conversation and use appropriate affect and gestures during the interaction. However, further investigation and observa tion at school may determine that the child adopts a social role and script, basing her persona on the characteristics of someone who would be reasonably socially skilled in the situation, and using intellectual abilities rather than intuition to determine what to say or do. An example of a camouflaging strategy is to conceal confusion when playing with peers by politely declining invitations to join in until sure of what to do, so as not to make a conspicuous social error. The strategy is to wait, observe carefully, and only par ticipate when sure what to do by imitating what the children have done previously. There can be other strategies to avoid active participation in class proceedings, such as being well behaved and polite, thus being left alone by teachers and peers; or tactics to passively avoid cooperation and social inclusion at school and at home, as described in a condition known as Pathological Demand Avoidance (Newsom 1983). Adults may consider there is nothing unusual about a girl who has an interest in horses, but the problem may be the intensity and dominance of the interest in her daily life: the young girl may have moved her mattress into the stable so that she can sleep next to the horse. If her interest is dolls, she may have over 50 Barbie dolls arranged in alphabetical order, but she would rarely include other girls in her doll play.

They are listed under the areas of Emergency muscle relaxant sciatica purchase generic voveran canada, Spinal spasms in chest 50mg voveran sale, Orthopaedics spasms kidney stones voveran 50mg mastercard, Post-Surgical and Rheumatology muscle relaxant gas purchase 50mg voveran amex. To accommodate variations in service requirements across state/territory jurisdictions and between organisations muscle relaxant medicines purchase voveran 50 mg mastercard, the examples provided in the performance cues for what independent competent practice may look like in action spasms diaphragm buy 50mg voveran overnight delivery, may be modified. This flexibility permits health service providers to pick and choose the non-core elements which align best with their service needs. However, it is imperative that the consistency and integrity of the standards are preserved therefore the remaining components of the standard must not be changed. Where performance criteria are not relevant to the advanced practice role, any competencies where the performance may be restricted in the population they service, or responsibilities required of the position holder, should be clearly documented in the range statement and a cross placed in the role relevance column in the competency standard. Do this in accordance with individual Consistently discern patients not appropriate for advanced musculoskeletal physiotherapy management strengths or limitations, any legal or organisational Engage in timely discussion and referral to expert colleagues for appropriate cases restrictions on practice, the environment, the patient Consistently apply local organisational requirements of patient flow in work prioritization, triage of profile/needs and within defined work roles referrals, booking of appointments and protocols for patients who fail to attend or are not C6. Biers Block Cuffs; Nitrous delivery systems providing appropriate care in the Demonstrate the ability to gain and record informed consent prior to undertaking a joint reduction or fracture interim reduction procedure Demonstrate an understanding of the principles of fracture reduction Describe and demonstrate the appropriate positioning for various fracture types 1. With appropriate supervision from medical team expert colleagues, perform reduction 1. Computer tomography for operative planning Document all aspects of the procedure undertaken including relevant information such as neurovascular status, position of fracture /joint etc. Evaluate and appraise patients with orthopaedic condition(s) Performance criteria Performance cues the performance criteria specify the level of the Performance cues provide practical examples of what an independent performer may look like in action performance required to demonstrate achievement of the element O1. Formulate management plan for patients with orthopaedic condition(s) Performance criteria Performance cues the performance criteria specify the level of Performance cues provide practical examples of what an independent performer may look like in action the performance required to demonstrate achievement of the element O2. Evaluate and appraise patients with spinal conditions competency standard Performance criteria Performance cues the performance criteria specify the level Performance cues provide practical examples of what an independent performer may look like in action of the performance required to demonstrate achievement of the element S1. Formulate management plan for patients with spinal conditions competency standard Performance criteria Performance cues the performance criteria specify the level of Performance cues provide practical examples of what an independent performer may look like in action the performance required to demonstrate achievement of the element S2. Evaluate and appraise patients with rheumatologic conditions competency standard Performance criteria Performance cues the performance criteria specify the level of the Performance cues provide practical examples of what an independent performer may look like in action performance required to demonstrate achievement of the element R1. The Bath Ankylosing Spondylitis Disease Activity Index) and / or diagnostic tests. Formulate a management plan for patients with rheumatological conditions competency standard Performance criteria Performance cues the performance criteria specify the level of the Performance cues provide practical examples of what an independent performer may look like in action performance required to demonstrate achievement of the element R2. This means that scope is determined, in part, by consistent self-reflection by physiotherapists on their competence to enact the activities within their scope of practice. Core clinical competencies for extended-scope physiotherapists working in musculoskeletal interface clinics based in primary care: a delphi consensus study. Advanced musculoskeletal physiotherapy clinical education framework supporting an emerging new workforce. Preparing residents to care for patients before, during and after image-guided procedures, is a major focus of the new program. Physicians may enter training directly from medical school (after completing a clinical internship) or they may enter after completing a residency in Diagnostic Radiology. Heathcare providers in this region struggle to meet the challenge of treating as many people as possible with very limited resources. Healthcare professionals from Stony Brook University worked with hospital staff to share methods and procedures to help them in this endeavor. We found that equally important as is the need for material goods is the necessity of education to use and maintain them properly. Traditionally, imaging for risk stratification and therapeutic planning involved catheter angiography. High resolution datasets can be acquired rapidly, which facilitates assessment of clinically labile or trauma patients. With appropriate protocol design, data acquisition requires limited operator dependence. The acquired 3D dataset is rich with information, but requires careful scrutiny by the interpreting physician. These data prove the need for an accurate and reliable method for assessment of the peripheral vasculature. Different acquisition schemes and contrast agent application protocols as well as different types of data sampling for static, dynamic, contrast and non contrast-enhanced imaging enable to tailor each exam to a specific question and patient respectively. The miniprobe was then inserted in the coaxial needle and placed in contact with the lesion. A volume of 2, 5ml of 10% fluorescein was injected intravenously before endomicroscopic imaging using a 488nm laser source. A pathologist performed side by side histological comparison and correlation in order to define interpretation criteria. This technique could be a valuable tool to help the radiologist target the lesion and monitor therapy, thus increasing biopsy yield and ablation precision. Despite this, many centers continue to utilize smaller gauge core systems to minimize perceived increased procedural complication risks. Post procedure hemorrhage was qualitatively evaluated (mild, moderate, severe) and pain was assessed using a 10 point rating scale at 1, 3 and 24 hours. Retrospective review of specimen adequacy included the # of cores obtained, length, and # of portal tracts. Differences in pathology metrics and pain scoring were assessed using Chi square and linear regression models. The mean # of portal tracts obtained with 16G biopsies was greater than 18G systems (14 vs. Thermocouple probes were placed percutaneously at the gallbladder fundus, neck, free wall, and gallbladder fossa. Histology: Five hours following completion of the last freeze cycle, the pigs were sacrificed. The gallbladder and ducts were resected en bloc and fixed in formalin with the thermocouple sites marked with sutures. Intra and post procedural heart rate, blood pressure, and oxygen saturation remained stable. Intra-procedural body temperature consistently decreased to below 95 F and recovered after the procedure. A 5 mm ablation margin was achieved about the gallbladder, including the adjacent hepatic parenchyma in the gallbladder fossa. Non-target ablation occurred in 1 animal (stomach), with less than 5 mm of ice ball penetration. Histology: Histologic specimens demonstrated denudation of the gallbladder epithelium, hemorrhage and edema within the muscularis layer, and an inflammatory infiltrate within the adventitia. Gastric inclusion in the ablation zone will require hydrodissection or continuous lavage in future experiments. Medicare specialty codes were used to determine if the procedures were performed by radiologists or other nonradiologist physicians. This volume increased progressively every year thereafter, reaching 28, 486 in 2013 (+102%). Open surgical drainage volume was 8146 in 2001, decreasing progressively to 6397 in 2013 (-21%). In 2001, 63% of all abdominal abscesses had been drained percutaneously; by 2013 this figure had risen to 82%. In 2001, radiologists performed 97% of all percutaneous abdominal abscess drainages, and this percent share remained unchanged in 2013. Of all abdominal abscesses treated in 2013 in Medicare patients, 79% were treated by radiologists. Although this database does not provide information on outcomes, percutaneous drainage is another good example of radiology-related value, in that an imaging-based interventional procedure developed by radiologists has largely replaced an older surgical approach that is more invasive, more costly, and carries greater morbidity for the patient. It provides useful functions including such as needle path planning, respiration monitoring, laser guidance, automatic needle positioning and guiding. To evaluate the accuracy and repeatability of the system in needle placement, two swine were used. The respiration of the swine was controlled with ventilator and intravenous injection of muscle relaxant. The spatial relation between swine and the robot system was registered with navigation system. After planning the needle path on workstation, the spatial information was translated to the robotic system. The robot system automatically angulates the needle to the target and depth of insertion is determined. Total of 22 needle insertion trials to 9 artificial target lesions at different needle paths was performed. In 12 trials, repeated insertion of needle was performed to assess reproducibility. Small cell lung cancer has a more rapid doubling time than non-small cell lung cancer, with most patients presenting with hematogenous metastases, and only approximately one-third presenting with limited-stage disease confined to the chest. Small cell lung cancer uncommonly presents with a solitary pulmonary nodule, and the disease does not appear to have benefited from Lung Cancer Screening. There are multiple neurologic and endocrine paraneoplastic syndromes associated with small cell lung cancer, with marked improvement on treatment of the underlying tumour. These include tracers targeting proliferation, receptor expression, and protein catabolism, investigating molecular events and processes beyond glucose metabolism. Preliminary data have indicated a potential role in the assessment of treatment response in lung cancer, but the method is not widely used. Solutions to these problems, such as improved anatomic coverage with wider detectors and table motion, reduced radiation exposure with iterative reconstruction, advanced postprocessing with dual blood supply algorithms, motion registration and correction, and volumetric perfusion analysis are addressed. Following thoracic radiation therapy, radiation pneumonitis (1-6 months following therapy) and radiation fibrosis (6-12 months following therapy) are typically identified in the lungs. However, complications such as esophagitis, esophageal ulceration, and radiation-induced cardiovascular disease may develop. Patients treated with chemotherapy may develop pulmonary and cardiovascular complications such as drug toxicity, organizing pneumonia, thromboembolic disease, vasculitis, and cardiomyopathy. Knowledge of the spectrum of expected treatment-related changes, potential treatment complications and the appearance of tumor recurrence is critical in order to properly monitor patients, identify iatrogenic complications, and avoid misinterpretation. A further advantage is the fact that ultrasound is a real time technique and vascular characteristics of lesions can be evaluated throughout the examination. This is particularly valuable in patients in whom other contrast agents are contraindicated. One notable example is the characteristic enhancement pattern of papillary versus clear cell renal cell carcinoma. The former typically enhances less than the surrounding parenchyma throughout the examination while the latter dramatically hyperenhances in the arterial phase. Again, quantitative imaging can further add to the confidence of the diagnosis in such cases. Due to its high temporal resolution, even a hyper-enhancement of a few seconds can reliably be detected, thus improving the characterization of focal liver lesions. A majority of malignant lesions can therefore be characterized as hypo-, iso or hyper-enhancing. During the arterial phase the tumor`s vessel architecture and direction of contrast filling is important for characterizing a lesions character. Due to a high spatial resolution, novel contrast imaging techniques allow detection of washed out lesions down to 3mm in size. Using time intensity analysis a change in contrast enhancement and kinetics helps in estimating tumor response to chemotherapy. At our institution, we have developed a 20-week course in which multidisciplinary teams solve meaningful problems to signifcantly improve performance in the department. This session will review the design and delivery of that course as well as other strategies for teaching quality improvement techniques. The most commonly used tools are thresholding, region growing, and manual sculpting. There are several 3D printing technologies that share similarities but differ in speed, cost, and resolution of the product. Some of the initial post-processing steps may be familiar to the radiologist, as they share common features with 3D visualization tools that are used for image post-processing tasks such as 3D volume rendering. It is highly recommended that participants review the training manual to optimize the experience at the workstation. The subject material of this course includes a diverse range of significant artifacts such as Egyptian and Peruvian mummies, Mesoamerican and Chinese ceramics, Mesopotamian stucco art, Judaic tabernacles, European medieval religious artifacts, Renaissance paintings, Stradivarius violins and Japanese wood sculptures. Some conservators now have access to 3D imaging software at museums or may conduct remote collaborative analysis of cases with radiologists via cloud-based 3D servers. In this session, we will have distinguished speakers from three nations discuss the challenges that organized radiology faces in their home countries and how they have tried to adapt in these circumstances. The topics will includes a wide ranging array of strategic considerations including but not limited to: aging patient populations, rising demand for healthcare, changing government regulation, methods of payment in the public (and where appropropriate the private) sector, regulatory issues, radiologist workforce issues and the training of the next generation of radiologists. A series of cases will be used to illustrate a few of these disorders, with attention to the most appropriate imaging protocol, the salient imaging findings, the anatomic and pathophysiologic factors that explain the findings, and the important differential. Elbow joint replacements include replacements of the radial head alone, replacements of the radiocapitellar compartment, and replacements of the ulno-trochlear compartment. The normal appearances and complications of smaller joint arthroplasties will be demonstrated utilizing various imaging modalities.

As detailed in Chapter 2 spasms right side under rib cage order 50mg voveran, the infant swallow and the adult swallow are quite differ ent and warrant individual discussions in their own right spasms right arm buy voveran 50mg lowest price. Once cannot assume that assessment techniques that are suitable for adults will also be suitable for babies muscle relaxant vs analgesic generic voveran 50 mg on-line, infants and children quinine muscle relaxant purchase voveran us. This chapter will discuss both (a) clinical assessments and (b) instrumental assessment techniques that are suitable for use with babies muscle relaxant 750 buy voveran 50 mg fast delivery, infants and children iphone 5 spasms purchase cheapest voveran and voveran. The ultimate goal of the clinical oral assessment is to de ne the pathophysiology and the extent of the feeding dif culties. In this problem-solving process, the evaluation of the oral cavity and its functions by observation plays a major role, and should occur prior to instrumental assessment. The feeding specialist must have a thorough understanding of normal function of the many interacting systems involved in feeding. In the clinical oral feeding evalu ation, oral anatomy, motor skills, re ex activity, responsivity and swallowing are examined. With this information, referrals can be made for further diagnostic test ing and multidisciplinary management where a speci c treatment plan can be devel oped. The clinical oral examination should therefore always be the initial assessment scheduled in a team evaluation. Oral structures are examined for malformations and for abnormalities of muscle tone and muscle mass. The lips, cheeks, jaw, tongue, hard and soft palate are examined at rest and during spontaneous movement. Palatal and labial clefts, micrognathia, deviant dental oc clusion, ankyloglossia and trismus are some of the most frequently seen anomalies. Assessment of oral motor function Oral motor skills have been described extensively in anatomy text books, develop mental and rehabilitation literature (Morris, 1982). A brief discussion of the most clinically relevant oral re exes in terms of infant sucking will be presented because the oral motor assessment in young infants occurs mainly by evaluation of the oral re exes. These oral re exes are de ned as programmed responses to a speci c sen sory input, generally a tactile stimulus, and they become modi ed or integrated into functional activity with increased maturity. The expression of oral re exes at any age can be quite varied, depending on a number of factors such as state of arousal or hunger. Oral re exes fall into two categories: temporary and permanent re exes (see Table 14. The cough and gag re ex are also called protective re exes as they are designed to protect the airway during feeding and to expel aspirated foreign material. The second mechanism to protect the airway is bronchial recep tor stimulation by excessive secretions with the purpose of clearing the lower airways of foreign material or mucus. It is important to observe the cough because the protective laryngeal cough is a prereq uisite for safe feeding and excessive coughing suggests lack of suck-swallow-breath coordination. Although the pres ence of a cough is imperative for safe feeding, it does not guarantee that the subject is a safe feeder. Many children with swallow dysfunction cough sometimes, but do not when they aspirate during deglutition. As coughing is the mechanism that protects the airway, the presence and effectiveness of the cough, and not the gag, needs to be considered in regards to safe oral infant feeding (Wolf and Glass, 1992). The purpose of the gag re ex is to protect the baby from ingest ing large items that can block the airway. It is elicited by touch pressure to receptors located on the tongue or pharyngeal wall causing a reverse peristaltic movement in the pharynx. The spot triggering the gag re ex moves with increasing age: in the newborn gagging is elicited in the mid-tongue area; when the baby matures, the gag gradually moves back to the pharyngeal wall or posterior portion of the tongue (Wolf and Glass, 1992). The status of the gag re ex does not predict the swallow ability as they are innervated independently but does provide information on the responsivity of the pharyngeal receptors (Dodds, 1989; Leder, 1996). The swallowi ng response has been obser ved i n the foetus at 12 to 14 weeks (I n ni r uber to and Tajani, 1981) and is present throughout life. The transverse tongue re ex is triggered by unilateral stimulation of the anterior 1/3 lateral border of the tongue. Lateral tongue movement occurs towards the side of stimulation and should be elicited bilaterally. The presence of this response is quite variable and is based on factors such as state. An absent re ex may re ect poor tactile sensitivity or neural integration (Wolf and Glass, 1992). Sucking is re exive in the newborn with a gradual transition to full volitional con trol of sucking by 3 to 4 months of age. The elicitation of the re ex varies depending on the type of stimulus (nutritive or non-nutritive) and can be inhibited by factors such as state or satiation (Wolf and Glass, 1992). The palmomental (Babkin) re ex can be elicited by giving bilateral pressure to the palms resulting in mandible depression and sucking movements of the tongue. A stimulus on the mandibular molar table leads to the elicitation of the phasic bite re ex resulting in rhythmic up and downward movements of the mandible (Sheppard, 1995). The Santmyer re ex is a swallow as a response to administration of a puff of air to the perioral area in the face of an awake non-crying infant (Orenstein et al. This swallow triggers a normal primary peristaltic sequence but responses vary in children from 11 months to 2 years of age. This re ex should be absent in neurologically normal children after the age of 2 years (Arvedson, 1993). The baby must adapt to the tactile characteristics of tools (breast, bottle, spoon or cup) and food in order to perform correct motor responses (Wolf and Glass, 1992). Since oral motor and oral sensory based feeding disorders can be distinguished (Palmer and Heyman, 1993), a struc tured sensory examination in and around the oral cavity is essential to delineate dif culties with the tactile components of feeding. Both sensory and motor attributes are considered, however it is not possible to observe sensations, only the reactions to sensations (Arvedson, 1993). A sensory baseline on consistency, taste, temperature, tools, area of stimulation and amount needs to be es tablished, which is de ned as the level of tactile input that the child can tolerate with out any discomfort (Palmer and Heyman, 1993). A wide range of tactile responses can be observed and these responses tend to form a continuum of function: absent responses, hyporesponsivity, normal tactile function, hypersensitivity and aversion (Wolf and Glass, 1992). When tactile responses are severely diminished or absent, a signi cant sensory impairment should be suspected and oral feeding may not be possible. In hyposensitivity, a strong stimulation is required, the responses are slow or partial. A hypersensitive response is exaggerated or out of proportion to the mag nitude of the stimuli. While similar to hypersensitive responses, aversive responses are even stronger and more negative. Both hypersensitive and aversive responses can be part of a global tactile processing problem or be localized to the face and mouth Table 14. During the exami nation the assessor will be able to determine whether the parents reports and percep tions are matching the observations (Reilly et al. Although considered most valuable by many authors, the clinical assessment is not designed to substitute for the instrumental techniques. The clinical examination remains assessor dependent and cannot rule out with certainty the possibility that patient is at risk for aspiration. Several multidisciplinary teams working with paediatric dysphagia have developed their own checklists, using the milestones of oral motor development as a reference to distinguish between nor mal and abnormal feeding skills. At present no universally accepted infant/paediatric feeding assessment tool exists (Arvedson, 1993). Therefore, knowledge of normal development and experience with oral motor and feeding function are often used as reference points for clinicians to evaluate children with abnormal functioning. The authors provide a most detailed and useful theory (evaluation and interpretation) behind the evaluated items as well as concordant therapy guidelines. Tongue and jaw movements during sucking are classi ed into normal, disorganized (lack of overall rhythm of the total sucking activity) and dysfunctional (interruption of sucking by abnormal movements of tongue and jaw) (Braun and Palmer, 1985; Palmer et al. Each item is divided in subcategories and is described by exclu sive characteristics forming a continuum from normal to abnormal (Conway, 1989). Lips, tongue and jaw movements and swallowing are rated separately for each type of food. The duration of meal, amount of intake, food consistencies, positioning, sucking from a nipple, sipping from a cup and coordination of suck-swallow-breath are rated. A summary provides an analysis of the quality of movement patterns and the developmental level of the observed behaviours (Morris, 1982). The Oral-Motor/Feeding Rating Scale is a rating scale for adequacy of lip, cheek, tongue and jaw movement during a typical meal (Jelm, 1990). This scale is useful from children 1 year of age through to adult clients and the assessment takes less than an hour. It can be used for initial observations of skill levels or to re-evaluate previously observed skills. The Multidisciplinary Feeding Pro le was described as the rst statistically based protocol for patients who are dependent feeders, particularly children with neurological de cits (Kenny, Koheil et al. Scaled numeric ratings are made for posture, tone, re exes, general motor control, oro-facial structures, oro-facial sensory input, oro-facial motor control, ventilation and functional feeding assess ment. The Assessment Scale of Oral Functions in Feeding rates the functionality of lip, jaw and tongue movement during liquid and solid foods. The scale assesses sipping from a cup, coughing, gagging, and hypersensitivity associated with swallowing (Ottenbacher et al. Abnormal oral structures, oral re exes, positioning, diet, utensils and feeding time can be marked on the provided checklist. The Preschool Motor Speech Evaluation (Earnest, 2000) is developed to assess oral motor and oral motor speech abilities in children from 18 months until 5 years of age. As well as focusing on speech and language development, this scale pro vides an oral motor examination at different levels of performance (spontaneous, imitation, cueing or elicitation) and oral sensory skills are screened at different age levels. The survey consists of two major parts: related factors and swal lowing competency. Swallowing competence is assessed dur ing liquid, chewable and non-chewable foods and addresses oral preparatory, oral, pharyngeal and oesophageal phases of swallowing. It provides the user with a raw score that can be interpreted by using a percentile ranking. These percentiles refer to the level of competency and the higher percentile rank refers to the more severely de cient swallow. The statistical analysis and nor mative studies on the base of this screening tool are well documented and are unique amongst the current available paediatric assessment scales. This allows the therapist to compare the patient to others with the same severity of disorder in regards to management needs. It is generally accepted that the clinical examination has its main focus on the oral phase of swallowing. In addition to the assessment scales discussed above, check lists can be useful for systematizing observations (Herman, 1991; Arvedson, 1993). Examples of published checklists include: the Infant Feeding Evaluation (Swigert, 1998) and the Feeding Assessment Checklist in the Manual of Feeding Practice (McCurtin, 1997). In general, published protocols and checklists evaluate many of the same vari ables but interpretation guidelines are lacking. Most of the scales imply that abnor mal deglutition will be re ected in the functional movements of the oral preparatory phase. The scales do not localize the dysfunction or reveal their possible causes (Sheppard, 1995). Authors tend to provide practical and accessible assessment tools but most of the scales lack normative data, standardization and validation. The clini cal examination often needs to be complemented with further instrumental assess ment to reveal the underlying cause of the oral feeding problem. Instrumental assessment has the potential to document oropharyngeal function objectively if selected and ap plied properly. Many different functional tests are available to assess oropharyngeal function during swallowing. Most of these assessment techniques remain subjective in the interpretation of the results. However, recently a few new paediatric techniques which allow objective measurement of oropharyngeal function have been developed and will be discussed here in detail.

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Diseases

• Chemophobia
• Chromosome 8, partial trisomy
• Cat scratch disease
• Infantile sialic acid storage disorder
• Idiopathic adolescent scoliosis
• Arthrogryposis due to muscular dystrophy
• Hirschsprung disease

References

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