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© 2021 EDIZIONI MINERVA MEDICA European Journal of Physical and Rehabilitation Medicine 2021 December;57(6):912-22
Online version at http://www.minervamedica.it DOI: 10.23736/S1973-9087.21.06802-7

ORIGINAL ARTICLE

Effect of oral sensorimotor stimulation

on oropharyngeal dysphagia in children
with spastic cerebral palsy: a randomized controlled trial
Amira M. ABD-ELMONEM 1 *, Sara S. SAAD-ELDIEN 2, Walaa A. ABD EL-NABIE 1

1Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Giza, Egypt; 2Department of Pediatric
Physical Therapy and Surgery, Faculty of Physical Therapy, Modern University for Technology and Information, Cairo, Egypt
*Corresponding author: Amira M. Abd-Elmonem, Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, 7 Ahmed
Elzayat St. Been Elsarayat, Dokki, 12624, Giza, Egypt. E-mail: dramira.salim2020@gmail.com

ABSTRACT
BACKGROUND: Children with cerebral palsy show various degrees of dysphagia causing late development of oral motor skills
AIM: The aim of this study is to investigate effect of oral sensorimotor stimulation on oropharyngeal dysphagia in children with spastic quad-
riplegia.
DESIGN: This was a double-masked, randomized controlled clinical trial.
SETTING: Outpatient Clinics of Faculty of Physical Therapy, Cairo University and Modern University of Technology and Information.
POPULATION: A convenient sample of 71 children age ranged from 12 to 48 months diagnosed with spastic quadriplegia, were randomly as-
signed into two groups.
METHODS: Children in the control group received 90 minutes conventional physical therapy training five times/week for four successive
months while those in the experimental group received 20 minutes of oral sensorimotor stimulation before the same program as in control group.
Oral motor function, body weight, segmental trunk control and gross motor function were assessed at base-line and after completing treatment.
RESULTS: Overall, 64 (32 in the experimental group, 32 in the control group) children completed treatment and data collection. The baseline as-
sessment showed non-significant difference regarding all measured variables while with-in group comparison showed significant improvement
in the two groups. The post-treatment comparisons revealed significant difference the oral motor function and physical growth in favor of the
experimental group (P<0.05). Finally, there was non-significant difference regarding segmental trunk control and gross motor function (P>0.05).
CONCLUSIONS: Oral sensorimotor stimulation has the capability to improve feeding in children with spastic cerebral palsy diagnosed with
oropharyngeal dysphagia.
CLINICAL REHABILITATION IMPACT: OSMS has effect on some of the essential oral motor skills that contribute toward the improvement of
feeding performance in children with spastic CP. The results of our study offer remarkable clinical importance for the children and their families.
(Cite this article as: Abd-Elmonem AM, Saad-Eldien SS, Abd El-Nabie WA. Effect of oral sensorimotor stimulation on oropharyngeal dysphagia in
children with spastic cerebral palsy: a randomized controlled trial. Eur J Phys Rehabil Med 2021;57:912-22. DOI: 10.23736/S1973-9087.21.06802-7)
Key words: Cerebral palsy; Deglutition disorders; Torso; Physical therapy modalities; Quadriplegia.

C erebral palsy (CP) is primarily a miscellaneous neu-

romotor disorder induced by unprogressive damage
to the immature brain in the prenatal through neonatal
period.1 According to motor impairment, the disorder is
categorized in to spastic (the most common type) repre-
senting 85%; dyskinetic (7%) which is represented by in-
voluntary movement (including dystonia and choreoath-
etosis); ataxic type (4%) and mixed type, which is mani-
fested by combination of these features.2 The spastic type
is farther labeled based on the topographic distribution of
impairment into unilateral; one side of the body is affected
representing 40-60%; or bilateral CP; manifested by in-
volvement of both sides of the body, including diplegia
which accounts for 10-36% of the cases, and quadriple-

912 European Journal of Physical and Rehabilitation Medicine December 2021

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OSMS FOR DYSPHAGIA IN SPASTIC CP CHILDREN ABD-ELMONEM
gia, which accounts for 24-31%. In quadriplegic type, the
involvement includes the trunk and the four extremities.3
Although the primary brain damage is unprogressive, CP
is characterized by wide range of associated permanent
impairments of movement, posture, perception, epilepsy,
cognition, communication, feeding and secondary muscu-
loskeletal disorders.4, 5
Patients with CP encounter swallow and feeding impair-
ments in infancy and childhood; which become worsen in
adulthood; with long meal times due to late development
of oral motor skills resulting in poor growth.4, 6 In-addi-
tion, they frequently experience oropharyngeal dysphagia
(OPD) including poor tongue lateralization which results
in failure of bolus transport, risk of aspiration, compro-
mised respiratory health, reduced pharyngeal movement
and inadequate lip closure which results in sialorrhea
(drooling).4, 7, 8 Moreover, alteration of the normal primi-
tive reflexes including biting, sucking and swallowing
affect feeding skills such as chewing and swallowing of
bolus. Furthermore, these manifestations are coupled with
the severity of movement impairments induced by CP.
Previous studies reported that, about 85% of children with
CP showed moderate to severe dysphagia while those with
profound dysphagia represented 15%. Moreover, approxi-
mately, 80% of children with quadrispastic CP have feed-
ing impairments with repeated aspiration of food during
swallowing.9
Several studies reported significant and direct associa-
tions between the gross motor functioning and the feeding
problems, malnutrition and limited physical growth among
children with CP. They declared that these associations are
primarily due to variable contributing factors including si-
alorrhea, constipation, food refusal and dysphagia. Addi-
tional factors include: abnormal muscle tone, uncontrolled
movements and muscle spasms which lead to lower func-
tional capacity, poor endurance and higher energy expen-
diture with inability to perform basic daily living tasks.10-13
Oral sensorimotor skills develop and become consolidated
rapidly through infancy and early childhood period. Oral
sensorimotor stimulation (OSMS) protocols should be in-
cluded in treatment of OPD applied in early infancy and
young childhood aiming to enhance the mobility, strength
and sensitivity of the oral motor structures responsible for
sucking, swallowing, and mastication in addition to modu-
lation of intraoral hypersensitivity.4, 14
Therefore, this study was conducted to explore the ef-
fect of oral sensorimotor stimulation on oral motor skills
and weight gain in children with spastic quadriplegia.
The authors hypnotized that; oral sensorimotor stimula-
Vol. 57 - No. 6 European Journal of Physical and Rehabilitation Medicine
tion might be an effective intervention to improve oral
motor skills and weight gain in children with spastic
quadriplegia.
Materials and methods
Study design and sitting
A double-masked randomized controlled design was se-
lected for testing the hypothesis of the current study from
November 2018 to April 2020. The study was conducted
at the Out-patient Clinics of Faculty of Physical Therapy,
Cairo University and Modern University of Technology
and information in accordance with ethical code stated in
Helsinki Declaration 1975. The clinical trial registration
number of the current study is NCT04524559.
Procedures
Ethical considerations
Ethical Committee Board approval of Faculty of Physical
Therapy, Cairo University was obtained before conducting
the study (No. P.T.REC/012/002829). A focus group meet-
ing was arranged for all children’s parents/legal guardian
in which the purpose, procedures, and potential benefits
and risks of the study was discussed. Children’s participa-
tion was authorized by asking all parents/legal guardians
to sign a consent form before baseline assessment.
Sample size calculation
A convenient sample of children with spastic quadriplegia
participated in this study. To avoid a type II error, a pre-
liminary power analysis sample size calculation, based on
data of pilot study using weight as the primary outcome,
was performed using G*POWER statistical software (ver-
sion 3.1.9.2; Kiel University, Kiel, Germany) and revealed
that the minimum required size of 58 (29 in each group).
The calculations were made using α=0.05, β=0.2 and ef-
fect size=0.75. Children who fulfilled the inclusion criteria
were enrolled in study. Accordingly, 70 children who met
the eligible criteria were included in the current study for
possible dropouts.
Subjects
All participants were children from both genders diag-
nosed with CP and referred to physical therapy by a neu-
rologist or general practitioner. Potential participants were
screened by the principal investigators at the Out-patient
Clinics of Faculty of Physical therapy, Cairo University
913
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ABD-ELMONEM OSMS FOR DYSPHAGIA IN SPASTIC CP CHILDREN

and Modern University for Technology and Information, Enrollment

Cairo, Egypt. The inclusion criteria were: 1) a diagnosis
Assessed for eligibility (N.=89)
of spastic quadriplegia; 2) age between 12 and 48 months;
3) scored ≤10 on an initial evaluation of Oral Motor As- Excluded (N.=18)
sessment Scale; 4) having at least a problem of oral motor Randomized (N.=70) - Not meeting inclusion
criteria (N.=11)
functions (drooling, swallowing, and/or sucking); inde- - Declined to participate
pendent feeding; 5) grade ≥2 spasticity according to the (N.=5)
- Other reasons (N.=2)
Modified Ashworth Scale;15 6) at level IV and V motor Allocation
function according to the Gross Motor Function Classifi-
cation System–extended and revised;16 7) and have partial
Allocated to intervention (N.=35) Allocated to intervention (N.=35)
head and trunk control. Children were excluded if they had - Received allocated intervention - Received allocated intervention
any of the following criteria 1) gum and/or dental prob- (N.=35) (N.=35)
lems; 2) congenital problems of mouth and soft plate; 3)
uncontrolled seizures; 4) any metabolic disorders; 5) car- Follow-up
diopulmonary disorders; 6) and significant mental prob- Lost to follow-up (give reasons) Lost to follow-up (give reasons)
(N.=3) (N.=3)
lems.
Degree of spasticity was determined with the Modified
Ashworth Scale (MAS).15 The MAS is frequently used to Analysis
evaluate the muscle tone changes during passive stretch Analyzed (N.=32) Analyzed (N.=32)
- Excluded from analysis (give reasons) - Excluded from analysis (give reasons)
to the investigated muscles through the full ROM. It is (N.=0) (N.=0)
based on 6 grade ordinal scale (0, 1, 1.5, 2, 3, 4) with nor- Figure 1.—CONSORT flow diagram.
mal muscle tone referred as 0, whereas a score of 4 is as-
signed for sever spasticity with no motion is possible. The
level of motor function was assessed by the Gross Motor in the current study; only 64 children completed the study
Function Classification System - Extended and Revised (32 children in each group). The participant enrollment
(GMFCS-ER). It is commonly used to determine the level flowchart is shown in Figure 1.
of mobility according to the child’s functional and walk- Outcome measures
ing capacity based on the chronological age. The GMFCS
classifies the functional abilities in to one of five levels. Primary outcome measure
Level I represent the ability of walking with no limitations,
meanwhile children with level V have severe impairments Oral motor skills
in head and trunk control and need comprehensive use of The Oral Motor Assessment Scale (OMAS); a reliable
assistive technology and physical aid. This study involved and accurate scale; is frequently used to assess oral-motor
children with GMFCS level IV and V.16 skills in young patients with neurological disorders. It is
Randomization a useful tool that can be used in assessment and interven-
tional studies. It consists of seven items compromising
The principal investigators first recorded all children with oral-motor skills (Table I). The assessment was conducted
spastic quadriplegia spastic CP. Those who met the eligi- with the child in comfortable supported sitting with the
ble criteria, 70 children, were included in the current study. head neutral position. The caregiver was allowed to feed
To achieve balance across the study groups, six homog-
enous strata were constructed based on the GMFCS level Table I.—Basic characteristics of participants of both groups.
and age as follow: GMFCS level IV and aged 12 to 24
Characteristics Experimental group Control group P value
months (N.=14); >24 to 36 months (N.=12); and >36 to
48 months (N.=18) or GMFCS level V and aged 12 to 24 Mean age, years 29.65±8.09 29.18±7.97 0.81 a
Gender
months (N.=10); >24 to 36 months (N.=6); and >36 to 48 Girls 17 (53%) 17 (53%) 1b
months (N.=10). Finally, an independent person, who was Boys 15 (47%) 15 (47%)
unaware of the study protocol and not otherwise in con- GMFCS Level, median (IQR) 4 (5.4) 4 (5.4) 1c
trol of the study, allocated each stratum to form a random IQR: inter quartile range.
a t-test; b χ2 test; c Mann-Whitney test.
sample for each group. Out of the 70 children participated

914 European Journal of Physical and Rehabilitation Medicine December 2021

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or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access
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OSMS FOR DYSPHAGIA IN SPASTIC CP CHILDREN ABD-ELMONEM
the child one of the following foods normally: fed with
a spoon soft food as yoghurt, a solid food as cookie or
fed a liquid food with a glass, with/without a straw. The
OMAS full assessment takes approximately 20 minutes
to be completed for each child. The assessment primarily
focused on feeding with five types of food (mash, semi-
solids, solids, cracker, and liquid bottle/cup). However,
according to the child’s age and preference, if food type
was affirmed to be improper for the child, the assessment
was carried out using the other types of food. Through-
out the assessment, the examiner did not interfere with
the way the caregiver fed the child but just observed and
scored each item of feeding process including chewing,
sucking and swallowing. Each item of the OMAS takes
30 second to be scored as passive (0), sub-functional (1),
semi-functional (2) and functional (3). The assessment
procedures were fulfilled in accordance with the scale de-
tailed instructions.17
Secondary outcome measures
Segmental trunk control
The Segmental Assessment of Trunk Control (SATCo)
was applied to assess upright trunk postural control in sit-
ting position. The scale is based on subdividing the trunk
into six segments. In respect with scale instructions the
head/neck is considered as one segment while the head/
trunk control is acquired segment by segment if upright
sitting posture can be maintained under three conditions
including: static control at static position, active control
while the child move the head and/or arm and reactive
control after external perturbation. The assessment pro-
cedures were applied in accordance with the SATCo test
guidelines. The Examiner, a person not otherwise par-
ticipated in the trial, recorded sagittal and frontal videos
for each child using a camera. Then, the investigators
scored the trunk control. The trunk segments according
to the SATCo include: head/neck, thoracic (upper, mid
and lower) and lumbar (upper and lower) segments. It is
an ordinal scale with a grade 1 to 7 is assigned for each
segment with the score 7 indicates that the infant cannot
retain independent sitting (no hand support). A score of 8
is given as full trunk control is gained. Each infant would
therefore have three scores to represent the static, active
and reactive trunk control.18
Physical growth
The body mass was measured via weight scale to detect
the physical growth changes overtime.
Vol. 57 - No. 6 European Journal of Physical and Rehabilitation Medicine
Gross motor function
The motor function assessment was conducted via the gross
motor function measure-88 (GMFM-88). The GMFM-88 is
a valid and reliable observational criterion-referenced tool
graded from 0-100 was developed to assess motor function
in children with CP or Down syndrome in five domains
with 88 items as follows: lying and rolling; crawling and
kneeling; sitting; standing; and walk-run-jump milestones.
These domains assess the extent of acquirement of gross
motor skills requiring postural control (sitting, kneeling,
and single limb stance). The GMFM-88 is beneficial and
highly sensitive for children with low functional abili-
ties. The functional abilities are assessed while the child
performed each item and scored as “does not initiate” (0),
“initiates” (1 = 10% of task), “partially completes” (2 =
10% to 100% of task, and “completes task” (3). The five
dimensions average percentage scores were calculated to
represent the total score.19
Intervention
Children in the control group received 90 minutes of neu-
rodevelopmental training (NDT)-based sequenced trunk
co-activation exercises. While those in the experimental
group received 20 minutes of oral sensorimotor stimulation
followed by 10 minutes rest before the same program as
in control group. The programs were applied via certified
physical therapists five days/week for 4 successive months.
Neurodevelopmental training-based sequenced trunk co-ac-
tivation exercises
The program focused on regaining typical movement, pro-
hibiting abnormal muscle tone, promoting postural reac-
tions and enhancing postural mechanisms. The intended
goals of the treatment program were achieved through:
• NDT was conducted to restore typical movement via
suppression of increased muscle tone, abnormal reflex pat-
terns and postural mal-alignment. Facilitation of head and
trunk control was achieved through sustained antigravity
positions as prone on forearms/hands, quadruped position,
sitting with hand weight bearing. Rolling, prone to sit and
sit to quadruped to sitting exercises were basically used to
achieve transitional activities;20, 21
• sequenced trunk co-activation (STA) exercises were
basically used for facilitation of functional activities through
trunk musculature dynamic co-activation of in the lateral
plane which is required for basic developmental milestones.
In the frontal plane, encourage the child to actively shift
his/her weight to maintain the weight-bearing side straight
915
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ABD-ELMONEM OSMS FOR DYSPHAGIA IN SPASTIC CP CHILDREN

while keeping proper active co-activation of trunk mus-
culature. Efficient trunk rotation is essential for acquiring
of equilibrium reactions and balance. Enhancement of ef-
ficient active trunk rotation as the child could achieve ac-
tive trunk musculature co-activation while maintaining the
weight-bearing side straight;22
• righting and protective reactions: once the children
had obtained the ability of sustaining exercise positions,
righting and protective reactions were conducted by using
physio-ball and tilting boards;20
• functional stretching exercises to preserve muscle and
soft tissues elasticity;20
• it is worth mentioning that the exercises applied in
each session were influenced by the age and the specific
functional abilities within the selected activity.
to decrease hypersensitivity of oral structures, increase jaws
movement, and reinforce muscle strength, improve tongue
movement and enhance oral motor organization.23-25
The OSMS protocol was applied by gloved hands and in
accordance with infection prevention protocol. To guaran-
tee the consistency of training, the physiotherapists were
previously instructed regarding the aims and the protocol
maneuvers. The child was placed in semi-reclined position
(aligned trunk posture) with the hips and lower extremi-
ties stabilized in flexion while the head and neck in neu-
tral position. This position allows visual observation of the
child throughout the training session to observe signs of
chocking or respiratory distress. Moreover, this position
allows obtaining the most convenient behavioral condition
for treatment.

Oral sensorimotor stimulation

Results
The training included OSMS protocol conducted before the Statistical analysis
child’s actual mealtime. The designed protocol comprised
modified perioral and intraoral maneuvers based on Fucile’s T-test was conducted for comparison of age between
protocol (Table II).23 The utmost aims of the protocol were groups. The χ2 test was used for comparison of sex distri-

Table II.—Oral motor training.

Site Maneuver Aim Duration
Cheek Compress the tissues at the base of the nose move your index toward the Stimulate lip closure, modulate 4 minutes
temporomandibular joint and down to the corner of the mouth muscle tone and improve cheeks
Internal cheek massage applied through index on the corner of the mouth, movement
move toward the molars and return to the corners of the mouth
Lips Place the index and thumb tips on the corner of the mouth, press the To enhance lip closure and improve 4 minutes
tissues and move towards the center of the upper then the lower lip ROM
Holding a straw between the lips. As the child can close the lips on a Improve lip closure 1 minute
straw, encourage the child to blow through it (easier than sucking)
Encourage sucking through the straw using thick liquids with children Improve lip closure and sucking 1 minute
having poor sucking skill. Use large diameter short straws then,
gradually decrease the diameter and increase the length of the straw
Gums Apply sustained pressure at the midline moving towards the back of the Improve sucking, modulate oral 4 minutes
mouth and return the midline. Repeat on both side of the upper and hypersensitivity, facilitate swallow
lower gums
Tongue Apply gentle strokes by index finger on lateral side from posterior part of
To improve tongue lateralization and 2 minutes
the tongue moving toward midline pushing it to the opposite side strength
Apply sustained pressure down of center blade of the tongue Allow formation of tongue groove, 1 minutes
improve ROM and strength,
enhance sucking and swallow
Place a drop of honey (any favorite flavor) on the index finger to Stimulate the tongue movement in 6 minutes
stimulate tongue active movement. Then place the drop of honey on the and outside the oral cavity (1 minute for each step)
inner side of cheek pocket. If the desired response was achieved place
the drop of honey on four corners of the mouth
Palate Place the index finger on the hard palate and apply pressure and massage Facilitate sucking and swallow 1 minute
from its center to the extremes
Jaw Jaw exercises included jaw opening, side to side movement and circular Improve jaw ROM 2 minutes
movement
Chewing Place small pieces of child’s favorite food (biscuits) over the molars Facilitate vigor of chewing 2 minutes
alternatively to stimulate chewing and gradually increase the
consistency of food used

916 European Journal of Physical and Rehabilitation Medicine December 2021

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OSMS FOR DYSPHAGIA IN SPASTIC CP CHILDREN ABD-ELMONEM

bution between groups and Mann-Whitney U-test was used
for comparison of GMFCS between groups. Normal dis-
tribution of data was checked using the Shapiro-Wilk test.
Levene’s test for homogeneity of variances was conducted
to test the homogeneity between groups. Mixed MANOVA
was performed to compare within and between groups ef-
fects on weight and GMFM-88. Post-hoc tests using the
Bonferroni correction were carried out for subsequent mul-
tiple comparison. SATCo and OMAS scores were com-
pared between groups by Mann-Whitney U-test and be-
tween pre- and post-treatment in each group by Wilcoxon
Signed Ranks. The level of significance for all statistical
tests was set at P<0.05. All statistical analysis was con-
ducted through the Statistical Package for Social Studies
(SPSS) v. 25 for windows (IBM SPSS, Chicago, IL, USA).
Subject characteristics
Table I shows the subject characteristics of the experimen-
tal and control groups. There was no significant difference
between both groups in the age, gender distribution and
GMFCS Level (P>0.05).
Effect of treatment on oral motor function
There was a significant increase in the post-treatment
OMAS scores of the experimental group compared with
the pretreatment (P>0.001), while there was no significant
change in OMAS scores of the control group (P>0.05).
There was a significant difference in the post treatment
OMAS scores in favor of the experimental group com-
pared with that of the control group (P>0.001). (Table III).

Table III.—Median values of OMAS pre and post treatment of both groups.
OMAS Experimental group Control group U value P value
Mouth closure
Pre-treatment 1 (1, 0) 0.5 (1, 0) 448 0.31
Post-treatment 2 (3, 2) 1 (1, 0) 36 0.001
Z value 5.09 1.41
P value 0.001 0.15
Lip closure on the utensil
Pre-treatment 0 (1, 0) 0 (1, 0) 496 0.8
Post-treatment 2.5 (3, 2) 0.5 (1, 0) 24 0.001
Z value 5.24 1.73
P value 0.001 0.08
Lip closure during deglutition
Pre-treatment 0 (1, 0) 0 (1, 0) 496 0.8
Post-treatment 2 (3, 2) 0 (1, 0) 30 0.001
Z value 5.1 1
P value 0.001 0.31
Control of the food during deglutition
Pre-treatment 0 (0, 0) 0 (0, 0) 448 0.17
Post-treatment 2 (3, 2) 0 (0, 0) 7.5 0.001
Z value 4.97 1.41
P value 0.001 0.15
Mastication
Pre-treatment 0.5 (1, 0) 0 (1, 0) 448 0.31
Post-treatment 2.5 (3, 2) 1 (1, 0) 24.5 0.001
Z value 5.17 1.8
P value 0.001 0.07
Straw-suction
Pre-treatment 0 (1, 0) 0 (0, 0) 432 0.17
Post-treatment 3 (3, 2) 0 (0, 0) 6 0.001
Z value 5.03 0.44
P value 0.001 0.65
Control of liquid during deglutition
Pre-treatment 1 (1, 0) 0.5 (1, 0) 480 0.61
Post-treatment 2 (3, 2) 1 (1, 0) 19 0.001
Z value 5.12 1.13
P value 0.001 0.25
Data expressed as median interquartile range.
U value: Mann-Whitney test value; Z value: Wilcoxon signed ranks test value; P value: level of significance.

Vol. 57 - No. 6 European Journal of Physical and Rehabilitation Medicine 917

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ABD-ELMONEM OSMS FOR DYSPHAGIA IN SPASTIC CP CHILDREN

Table IV.—Median values of SATCo pre- and post-treatment of both groups.

SATCo Experimental group Control group U value P value
Static
Pre-treatment 2 (2, 2) 2 (2, 2) 486 0.66
Post-treatment 5 (5, 4) 5 (5, 4) 506.5 0.93
Z value 5.06 5.09
P value 0.001 0.001
Active
Pre-treatment 2 (2, 1) 1 (2, 1) 453 0.37
Post-treatment 4 (5, 3) 4 (4, 3) 444.5 0.33
Z value 5.06 5.07
P value 0.001 0.001
Reactive
Pre-treatment 0 (1, 0) 0 (0.75, 0) 448 0.28
Post-treatment 2.5 (3, 2) 2 (3, 2) 466 0.49
Z value 5.14 5.03
P value 0.001 0.001
IQR, interquartile range; U value: Mann-Whitney test value; Z value: Wilcoxon signed ranks test value; P value: level of significance.

Effect of treatment on trunk control
There was a significant increase in the post-treatment
static, active and reactive scores of SATCo in the experi-
mental and control groups compared with the pretreatment
(P>0.001). However, post treatment comparison between
groups revealed no significant difference in SATCo scores
(P>0.05) (Table IV).
Effect of treatment on weight and gross motor function
There was a significant interaction of treatment and time
(F=199.24, P=0.001). There was a significant main effect
of time (F=991.91, P=0.001). There was a significant main
effect of treatment (F=10.39, P=0.001). Table V showed
descriptive statistics of weight and GMFM-88 and the sig-
nificant level of with-in and between groups comparison.
Regarding within group comparison, there was a signif-
icant increase in weight and GMFM-88 in the experimen-
tal group post-treatment mean values compared with the
pretreatment (P>0.001). There was no significant change
in weight of the control group post-treatment (P>0.05),
while there was a significant increase in GMFM-88 post-
treatment mean values compared with the pretreatment
(P>0.001).
Regarding between group comparisons, there was no
significant difference in weight and GMFM-88 between
both groups’ pretreatment mean values (P>0.05). Between
groups post-treatment comparisons revealed a significant
difference of weight in favor of the experimental group
compared with that of the control group (P<0.001); while
there was no significant difference in GMFM-88 between
groups post-treatment mean values (P>0.05) (Table V).

Table V.—Mean weight and GMFM-88 pre- and post-treatment of both groups.

Parameters Experimental group Control group MD (95% CI) P value

Weight, kg
Pre-treatment 10.04±1.04 9.98±1.23 0.06 (-0.5; 0.63) 0.82
Post-treatment 12.46±0.78 10.1±1.3 2.36 (1.82; 2.9) 0.001
MD (95% CI) -2.42 (-2.57; -2.26) -0.12 (-0.28; 0.04)
P value 0.001 0.14
GMFM-88 (%)
Pre-treatment 21.37±2.09 20.94±2.51 0.43 (-0.72; 1.58) 0.45
Post-treatment 38.17±3.6 37.77±3.54 0.4 (-1.4; 2.17) 0.66
MD (95% CI) -16.8 (-18.01; -15.58) -16.83 (-18.04; -15.62)
P value 0.001 0.001
MD: mean difference; CI: confidence interval.

918 European Journal of Physical and Rehabilitation Medicine December 2021

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OSMS FOR DYSPHAGIA IN SPASTIC CP CHILDREN ABD-ELMONEM
Discussion
Children with generalized severe motor impairments as
spastic quadriplegia are likely to have swallow and feeding
disorders with high risk for aspiration with possible pulmo-
nary sequel and long frustrating mealtimes. The common
oral motor disorders among this population include weak
suck, poor lip closure and tongue movement, exaggerated
tongue thrust and bite reflex with oral hypersensitivity.9, 26-28
The current study aimed to ascertain the effect of OSMS
on oropharyngeal dysphagia in children with spastic CP.
The baseline assessment revealed feeding problems includ-
ing poor lip and mouth closure as well as impaired control
of food and liquid during deglutition. Furthermore, they
showed poor segmental trunk control and gross motor func-
tion. This comes in accordance with Erasmus et al.29 who
stated that, children with CP show wide range of sensory
impairments of the oral region including recognition and lo-
calization of sensory input due to abnormal sensory thresh-
old. Similarly, Weindling et al.30 reported that, children with
CP have abnormal oral sensory threshold with impaired
abilities to localize the sensory input within the oral area
which is crucial for chewing and controlling the bolus of
food according to bolus volume and viscosity.
The main outcomes of our study was that, OSMS influ-
enced significant refinement when comparing post-treat-
ment measurements between both groups after four months
of treatment in favor of the experimental group while the
control group showed non-significant change in respect the
oral motor function and physical growth. However, within
group comparison indicated significant improvement in
segmental trunk control and gross motor function in both
groups. Our results offer preliminary support for the as-
sumption that OSMS could improve oral motor and feeding
performance in children with spastic CP. The results of our
study offer remarkable clinical importance for the children
and their families.
Our study suggests two possible concepts for these find-
ings. One concept is the application of OSMS conducted
with the child in proper position and intended to improve
sensory perception of the oral region, modulating abnor-
mal muscle tone and inhibit tongue thrust and the bite re-
flex among children with spastic CP. The second concept
is the NDT-based sequenced trunk co-activation exercises
program which aimed to modulate muscle hypertonicity, in-
hibit awkward movement patterns and enhance head/trunk
control and gross motor function.
Previous studies documented that, OSMS is widely con-
ducted in infants and children with CP aiming for enhancing
Vol. 57 - No. 6 European Journal of Physical and Rehabilitation Medicine
oromotor function and feeding. It has been reported that,
different sensory stimulation approaches applied to the oral
region before mealtime are effective in modulating abnor-
mal muscle tonicity during feeding. Moreover, it helps to
diminish tongue thrust and the bite reflex which enhance
swallow and chewing abilities in children with CP.7, 30
Our results are in consistent with previous studies stated
that, oral motor exercises either active or passive are effec-
tive and could be used to enhance muscle strength via re-
cruitment of extra motor units as the size of muscle fibers is
enlarged. Moreover, slow stretching of spastic muscle inhib-
its stretch reflex through manipulating the muscle spindles
and reduces muscle tone.24, 31 Arvedson,7 documented that,
passive exercises (e.g. massage, stroking and passive range
of motion exercises) are effective in improving circulation,
preserve or improve joint flexibility, modulating abnormal
tone, inhibiting abnormal oral reflexes and desensitizing the
oral area.
Our study revealed considerable increase in the body mass
in the experimental group with non-significant difference in
the control group. This may be accredited to improvement
of oro-motor skills in those children which enabled them to
eat a variety of foods and for large amount. These findings
are comparable with that reported in previous studies stated
that, swallow or oral-motor impairments may have a nega-
tive influence on nourishment or overall health condition in
developing children with improper growth.9, 32
Liu et al.33 concluded that basic oral exercises had a fa-
vorable effect on feeding skills in premature infants so that
weight gain was safely improved in these children. Simi-
larly, Byars et al.34 stated that, the influence of oro-motor
training induced improvement in children with feeding
problems as increasing the calories and liquid/solid intake
in addition to decreasing bottle dependence, enhancing oro-
motor skills and increasing the variety of the foods textures
they consumed.
Further in consistence with our results, Garcia et al.35 men-
tioned that maintaining oral feeding as long as possible is
very important for physical growth and development mainly
in children with dysphagia in particular those with CP. Re-
sults of this study come in consistence with the findings of
previous studies documented significant effects of oromotor
training reported as improvement in the weight of children
with neuromotor deficits. Moreover, children showed prog-
ress in spoon-feeding, swallow, biting, chew, cup drinking
and decreased drooling after oromotor training.36, 37
Our study results are contradicting the findings of Ernst
et al.38 They reported that nonnutritive oromotor exercises
had no effect on feeding functions in premature children.
919
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ABD-ELMONEM OSMS FOR DYSPHAGIA IN SPASTIC CP CHILDREN
Their finding could be due to the protocol and duration of
intervention and the population was studied. The results of
this study disagreed with Gisel39 who studied the impact of
10-20-week OSMS on aspiration frequency, feeding skills
and physical growth on 27 children with CP. He found
that, oromotor training had non-significant effect on feed-
ing skills and physical growth but was found to decrease
feeding problems caused by aspiration. Our results also
contradict with Rogers,40 who stated that, oral feeding train-
ing protocols for children with CP may enhance oral motor
function, but these protocols have not been shown to be ef-
ficient in improving feeding capacity or weight gain. The
contradictions of the results may be illustrated by limiting
of a specific type of CP in some studies or including differ-
ent types in the others, application of different protocols for
oral motor training.
It worth mentioning that some may argue the weight gain
recorded in the experimental group. Several studies docu-
mented the importance of implementing OSMS in early in-
fancy and childhood to ensure proper nutrition, adequate ca-
loric intake, and hydration in children with feeding problems
to prevent weak growth, and nutritional disorders.33, 41, 42 Al-
though, these studies recommended that SOMS are essen-
tial during the early childhood but later, nutrition behavior
and calorie intake must be precisely monitored to provide
the substantial energy for development with proper weight
control among children with disabilities.
It seems that other elements as postural components have
a radical importance in feeding disorders of children with
CP who have motor impairments in the trunk and neck/head
alignment. Those children commonly show poor postural
control and motor performance leading to deterioration of
jaw and mandible control, poor swallowing and feeding dis-
orders.1
This is also supported by previous studies reported that,
management enhancing neutral position of the pelvis allow
biomechanical alignment of the spine and neutral head posi-
tion in which the tongue and jaw move freely for oral-motor
function with improved swallowing and jaw control and re-
duce the risk of aspiration.43, 44
Louise,45 demonstrated that, it is essential to consider the
child’s position prior to implementation of any therapy. As
while in seated fully supported with proper posture of the
head and trunk, you can provide the basis for improving oral
structures control during feeding.
The results of the current study clarified that, there
was considerable improvements in trunk control and
motor function in both groups. Regarding our study the
NDT based conventional physical therapy program was
920 European Journal of Physical and Rehabilitation Medicine December 2021
conducted five times a week for four successive months.
The significant improvement reported in the study groups
could be attributed to the frequency and duration of the
intervention program. Besios et al.,46 studied the effect
of the NDT in children with CP. They approved that,
there were significant changes in GMFM-88 scores after
implementation of NDT and its positive effects remained
through follow-up assessment (a month later). They sug-
gested that a high-frequency short-duration NDT-based
sequenced trunk co-activation exercises protocol can re-
sult in clinically significant changes for infants with pos-
tural and movement dysfunction.
Our findings match the findings of a recent study47 that
intended to explore the effects of trunk control exercises
on motor function. Their results showed that, appending
exercises which target strengthening trunk muscles to the
NDT intervention can potentially improve of motor func-
tion in children with CP. Similarly, labaf et al.20 concluded
that the NDT induced significant improvement of gross
motor performance on GMFM dimensions in children
with CP.
Our results are also corroborated by a previous study
stated that NDT intervention has positive effects and
caused significant improvements of motor functions.21
Similarly, previous studies documented that, trunk control
is a valuable index of gross motor functions and is directly
related to postural stability, gait and functional capability
essential to perform daily life activities.48, 49
Limitations of the study
Overall, our study supports the hypothesis that OSMS is
an effective intervention that improves oral motor skills in
children with spastic CP. However, this study is not exempt
of limitations. The major limitations of the current study
were lack of re-evaluation and follow-up after completion
of the intervention. Another limitation was that drooling
was not considered as a contributing factor to OPD. Fi-
nally, the body mass index was not estimated which is es-
sential indicator for weight control among children with
disabilities. These potential sources of bias should be con-
trolled in future studies to provide a better understanding
and overview about the feasibility of OSMS on OPD in
children with spastic CP.
Conclusions
Oral sensorimotor stimulation has the capability to im-
prove feeding in children with spastic cerebral palsy diag-
nosed with oropharyngeal dysphagia.
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OSMS FOR DYSPHAGIA IN SPASTIC CP CHILDREN ABD-ELMONEM
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cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
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ABD-ELMONEM OSMS FOR DYSPHAGIA IN SPASTIC CP CHILDREN

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Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.
Authors’ contributions.—Amira M. Abd-Elmonem and Sara S. Saad-Eldien have given substantial contributions to the conception or the design of the manu-
script. Sara S. Saad-Eldien and Walaa A. Abd El-Nabie to acquisition, analysis and interpretation of the data. All authors have participated to drafting the
manuscript. Amira M. Abd-Elmonem revised it critically. All authors read and approved the final version of the manuscript. All authors contributed equally
to the manuscript and read and approved the final version of the manuscript.
Acknowledgements.—The authors would like to express their sincere appreciation to all physiotherapists who participated in the study procedures. The au-
thors cannot forget to thank all children and their parents, for their collaboration in this study.
History.—Article first published online: May 7, 2021. - Manuscript accepted: May 4, 2021. - Manuscript received: January 10, 2021.

922 European Journal of Physical and Rehabilitation Medicine December 2021