ISMAR: an autotherapeutic device assisting patients from drooling to articulated speech.

This overview of three decades of clinical experience with oral therapies complemented by oral devices-vestibular screens (VS) and ISMARs (Innsbruck sensory motor activators and regulators)-tries to put these devices into an oral functional context including postural control of mobile structures both inside and outside the mouth-down to the feet. ISMARs have certain unique features which teach a person not only better postural control of the lower jaw and, hence, hyoid bone and tongue, but also to stimulate movements of lips and tongue to improve salivary control, functions of eating and drinking and the domain of communication, e.g. facial movements and articulation of speech. A review of the relevant postural background is provided and the mechanisms are explained and may serve as models for other oral therapies. The inter-relation and multi-functionality of muscular connections throughout the body explains the uniformity of facial, oral and pharyngeal dysfunctions in different conditions such as cerebral palsy, Moebius syndrome, chronic nasal congestion or developmental retardation and exposes patients with oral dysfunctions to the risks of vicious circles. However, at the same time the opportunity is given to trigger beneficious circles. Three principles of postural control in and for the neck region are postulated. Clinical observations and experiments with volunteers are described and some supporting information is given-hopefully enough to stimulate clinical work and give rise to further experimental work to illuminate this field which is extremely important for both human communication and inter-relation.

Use of an Innsbruck sensorimotor activator and regulator (ISMAR) in the treatment of oral motor dysfunctions: a single case report.

Many patients with cerebral palsy have difficulties during the oral preparatory phase and also during the food transport phase (swallowing), and oral-sensorimotor therapy is practised with these individuals. With oral-sensorimotor therapies, the functioning of the lips, cheeks, tongue and pharyngeal structures, and the interplay between these structures, can be improved. An Innsbruck sensorimotor activator and regulator (ISMAR) is one of the appliances used for oral-motor therapy. The purpose of this study is to describe the appliance and report a patient using ISMAR.

Impact of oral appliance therapy: are oral skills and growth maintained one year after termination of therapy?

To determine the impact of intraoral appliance (ISMAR) therapy on functional feeding skills and growth, children with cerebral palsy and moderate dysphagia were followed a full year after termination of one year of ISMAR therapy. Seventeen children, 6.6-15.4 years old (mean age = 10.2 +/- 3.0 years), were divided into two groups: group A (n = 9) continued to wear the appliance and group B (n = 8) no longer wore the appliance. Generalized estimating equations (GEE) were used to test differences between the two groups over time while accounting for the dependence for the repeated within-subject measurements. No significant differences were found in the 7 domains of functional feeding. Significant time x group interactions for weight (kg and z-score 0.01 < p < 0.05) were found. However, post hoc analyses showed that there were no significant differences in weight changes between the two groups at either 18 or 24 months of followup. These results suggest that during a one-year period of followup, maturation was equally effective as ISMAR therapy.

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.

"Whole body" mobility after one year of intraoral appliance therapy in children with cerebral palsy and moderate eating impairment.

The reciprocal influence of body postures on the oral structures, but also of the oral structures on body postures, has been proposed by clinicians and is taken into consideration when treating children with poor postural control and moderate to severe eating impairments. However, this relationship has not been rigorously investigated. The purpose of this study was to document the possible relationships among oral-motor, postural, and ambulatory control. Ambulatory skills [exclusive use of wheelchair (w/c) vs w/c and ambulation], postural control when sitting, "pathologic" reflexes, and lip and tongue posture were recorded before and after one year of therapy with an intraoral appliance (ISMAR) in 20 children with cerebral palsy and moderate eating impairment. Significant improvement occurred in sitting (head-trunk-foot control) following one year of ISMAR therapy. Ambulatory status also significantly improved above the level of maturation. Half of the children showed marked improvement in oral posture, i.e., their resting mouth posture was closed rather than open. These results support an hypothesis of interaction between oral structures and postural control of the "whole body." Further studies are needed to determine the controls of such a relationship.

The Innsbruck Sensorimotor Activator and Regulator (ISMAR): construction of an intraoral appliance to facilitate ingestive functions.

Oral sensorimotor therapy is practiced widely with children who have neuromotor impairments, such as cerebral palsy and eating problems. Although improvement in ingestive skills can be achieved in the short term (5 months), long-term effects (over 12 months) remain to be examined. Interventions with intraoral appliances are used in children with moderate impairments of the oral-motor system and offer an opportunity for long-term treatment. Instead of the daily oral sensorimotor exercises, which must be provided by a qualified therapist, the intraoral appliance is worn during the night, so that the "therapy" is initiated and controlled by the child. The purpose of this paper is to describe the appliance: its prescription, fabrication and therapeutic use. A case study illustrates that improvement in ingestive skills, efficiency of eating, and marked weight gain can be achieved.

[Nemaline myopathy: an unusual course]. / Nemaline-Myopathie: Ein besonderer Verlauf.

A girl presents immediately post partum with postures and movements typical for severe muscular hypotonia (floppy infant). Her sucking and swallowing abilities are reduced. There is marked drooling. Broad alveolar ridges give the impression of a high-arched palate. Floppy infant-screening (muscle enzymes, EMG, NCV) was within normal ranges apart from a slight elevation of aldolase. Muscle biopsy performed at the age of two years revealed the diagnosis of nemaline myopathy. An onset of the disease with severe muscular hypotonia during neonatal period usually is linked with rapidly progressing, mostly lethal outcome. Our patient--in contrast--seems to suffer from a mild form.

[Therapeutic possibilities for the handicapped child]. / Therapiemöglichkeiten für das behinderte Kind.

This article reviews the papers on therapies for handicapped children which were delivered at the 20th annual "Fortbildungskurs der Osterreichischen Gesellschaft für Kinderheilkunde", Obergurgl, 1987. Central topic was the oral region. J. P. Guggenbichler, Innsbruck (pathogenesis) and Sieglinde Zschiesche, Erlangen (The Erlangen interdisciplinary treatment approach) covered genesis and treatment of cheilo-gnatho-palato-schisis. Background and therapy-principles for dysfunctions of the facial, oral and pharyngeal region were discussed by H. Haberfellner, Innsbruck. He also described therapy by use of modified orthodontic devices (ISMAR: Innsbruck sensori-motor activators and regulators) and Schönherr's vestibular screen. The same was done for Castillo-Morales' palatal plates by J. Limbrock, München. Essence and changing features were described for Bobath concept and Petö's Conductive Education by H. Haberfellner and for Vojta's and Castillo-Morales' therapy by J. Limbrock. This part was concluded by a survey on therapeutic sports (H. Haberfellner): Riding on horseback, swimming, skiing and cross-country skiing, also for spinally injured patients.

[Development of premature children below a birth weight of 1,500 g]. / Entwicklung frühgeborener Kinder unter 1 500 g Geburtsgewicht.

5,928 newborn infants were admitted between the years 1974 and 81 to the University of Innsbruck, Department of Pediatrics. 418 (7%) of them were premature infants with a birthweight of less than 1,500 g. 21 (18%) of the premature infants with a birthweight below 1,000 g survived (21 of 117). Among those 21 surviving infants only 7 (33%) had an appropriate birthweight, 14 (67%) were too small for their gestational age. Survival in the weight range between 1,000-1,500 g was 71% (213 of 301). The percentage of dystrophic infants was 23% (49 of 213). The place of birth has a significant influence on the survival of these very small immature infants. 24% (n = 84) of patients delivered in the nearby Clinic of Obstetrics survived in contrast to only 3% (n = 33) of those born in peripheral hospitals. This is reemphasized by the evaluation of psychomotor development of surviving infants; of 14 patients with normal psychomotor milestones 13 were delivered at our obstetric department. 157 patients were regularly followed up during their first year of life. 43% can be considered normal by all parameters. 57% show some abnormalities in their development during the first years of life. During their second year of life only 13% showed psychomotor problems and this number decreased to 5% in the third year. All these children show varying degrees of hemi- or diplegia and/or seizure activities. A routine check up at 12 month of life seems important as all patients with permanent retardation can be correctly diagnosed at this age.(ABSTRACT TRUNCATED AT 250 WORDS)

[Follow-up study of children with hypoxia following pneumothorax]. / Nachuntersuchung von Kindern mit Hypoxämien nach Pneumothorax.

A group of 23 children suffering from neonatal hypoxia (pO2 less than 50 mm Hg) due to pneumothorax was examined at an average age of 14 months. Evaluation at this early developmental stage was accomplished by combination of "Motoscopy", "Vojta's postural reactions" and the "Concept of provocation of normal behaviour under adverse conditions". Development of the group as a whole was found to be unexpectedly good: Two children with cerebral palsy, and seven with yet undefinable developmental course versus fourteen obviously normally developing children. Pneumothorax and drainage did not cause the frequent transient postural asymmetries in this group.

[Interaction of general body posture, oral and facial region. I. Literature and clinical findings (author's transl)]. / Wechselwirkungen zwischen Gesamtkörperhaltung, Mund und Gesichtsbereich. I. Literaturüberblick und klinische Beobachtungen.

Postural control of head and trunk is basic for adequate posture and movement of eyes, facial, oropharyngeal and limb muscles. On the other hand there are also influences of ocular and oro-pharyngeal movements on posture and movements of neck, trunk and limbs. After a review of experimental and clinical observations several pertinent own observations are presented. The advantage of the systematic use of these phenomena for habilitation and rehabilitation of patients with motor handicaps is stressed.

[Interactions of general body-posture, oral and facial region. II. Polyelectromyographic investigations (author's transl)]. / Wechselwirkungen zwischen Gesamtkörperhaltung, Mund und Gesichtsbereich. II. Polyelektromyographische Untersuchungen.

Based on previous observations we used surface poly-electromyography (EMG) to trace influences of eye and tongue movements on skeletal muscles. While we could not show ocular effects using this method, we could demonstrate clearcut influences of lingual lateral movements on the sternocleidomastoid (SCM) muscles. Voluntary lateral movements of the tongue inside the mouth were accompanied by an increase of the amplitude of the EMG of the contralateral SCM muscle, while lateral movements of the tongue outside the mouth produced an increase of the amplitude of the ispilateral SCM muscle. Frequency characteristics of the EMG remained unchanged. There were no such alterations with passive tongue movements. These seemingly postural lingual reflexes are discussed in the light of Bosma's concept of maintenance of pharyngeal airways.

Asymmetry in children with cerebral palsy and oral structure.

Twenty-six children with cerebral palsy were examined with respect to structural asymmetry of the mouth. In 19 children there were clear cut correlations between symmetry/asymmetry of voluntary function and the oral findings. Patients with symmetrical patterns of movements had symmetrical dentition, while in those with asymmetrical function the favoured side corresponded to the side with structural changes. Apparent exceptions to this rule in 7 children could be resolved in 6 by analysis of their complex case histories. Fifty normal controls showed oral asymmetries of nearly identical frequency and magnitude. In this respect there is no difference between the normal and handicapped group.