Assessment of autonomic nervous system dysfunction associated with peripheral neuropathies in the context of clinical neurophysiology practice.

Peripheral neuropathies may involve the small diameter nerve fibers of the autonomic nervous system. In the presence of clinical signs compatible with dysautonomia, it is very difficult to affirm that these signs are really linked to an alteration in postganglionic autonomic innervation, and not to a lesion of the central nervous system or to a direct damage to the tissues and innervated organs. Also, in the context of the investigation of peripheral neuropathies, there is an interest in performing objective and quantitative assessment of distal autonomic innervation. The corresponding autonomic tests are mainly based on the exploration of sudomotor or vasomotor disorders of the limb extremities. In this article, we provide an overview of the various tests available for the study of the autonomic nervous system in clinical practice, including vasomotor reactivity tests, in particular based on laser Doppler techniques, and sudomotor tests, based on axon-reflexes produced by iontophoresis of cholinergic drugs or on the simpler measurement of electrochemical skin conductance by the Sudoscan® device.

Assessment of Laryngeal Sensory Function using a Tactile Aesthesiometer in Healthy Adults.

INTRODUCTION: Laryngeal sensory function in healthy adults was assessed through the delivery of tactile stimuli using Cheung-Bearelly monofilaments. METHODS: 37 healthy adults were recruited with 340 tactile stimuli analyzed. Four calibrated tactile stimuli were delivered to three laryngeal sites: false vocal fold (FVF), aryepiglottic fold (AEF), and lateral pyriform sinus (LPS). Primary outcome was the elicitation of laryngeal adductor reflex (LAR). Secondary outcomes were gag, patient-reported laryngeal sensation (PRLS), and perceptual strength. Analysis was performed with mixed effects logistic regression modeling. RESULTS: Positive LAR was observed in 35.7%, 70.2%, and 91.2% of stimuli at LPS, AEF, and FVF respectively. LAR rates were significantly associated with laryngopharyngeal subsite (p < 0.001), tactile force (p = 0.001), age (p = 0.022) and sex (p = 0.022). LAR, gag, PRLS, and perceptual strength significantly increased as a more medial laryngeal subsite was stimulated and as stimulus force increased. Each of the ten years of age increase was associated with 19% reduction in odds of LAR (aOR = 0.81, 95% CI [0.68, 0.97]; p = 0.022). Male gender was associated with a 55% reduction in odds of LAR (aOR = 0.45, 95% CI [0.23, 0.89]; p = 0.022). CONCLUSION: LAR elicitation capability decreases in the male gender, aging, and a more lateral subsite. This study provides insight into the pathophysiology of hypo- and hyper-sensitive laryngeal disorders and is paramount to making accurate diagnostic assessments and finding novel treatment options for various laryngological disorders. Laryngoscope, 133:2525-2532, 2023.

Methods of Cough Assessment and Objectivization.

Cough is one of the most important airway defensive reflexes aimed at removing foreign particles or endogenously produced materials from the airways and provides protection against aspiration. Generally considered, cough is a vital physiological defensive mechanism for lung health. However, in case of cough dysregulation this reflex can become pathological and leads to an adverse influence on daily life. Therefore, it is necessary to effectively evaluate the severity of cough for its diagnosis and treatment. There are subjective and objective methods for assessing cough. These methods should help describe the heterogeneity of cough phenotypes and may establish better treatment by monitoring response to nonpharmacological or pharmacological therapies. It is important to keep in mind that the clinical assessment of cough should include both tools that measure the amount and severity of the cough. The importance of a combined subjective and objective evaluation for a comprehensive assessment of cough has been advocated in the guidelines of the European Respiratory Society on cough evaluation. This review article provides an overview of subjective and objective methods for assessing and monitoring cough in children and adults comparing to animal models. Key words Cough frequency; Cough intensity; Cough reflex sensitivity; Cough monitors; Cough assessment.

Factor Analysis of the Einstein Neonatal Neurobehavioral Assessment Scale in Infants with Congenital Heart Disease and Healthy Controls.

Background: Administration of the Einstein Neonatal Neurobehavioral Assessment Scale (ENNAS) can be time-consuming, and items can be highly correlated. We aimed to determine: (1) its factor analytic structure; (2) the validity of the factor structure; and (3) the associations of physiologic measures with factor scores. Methods: A factor analysis reduced 21 ENNAS items into 5 factors in 57 congenital heart disease (CHD) and 35 healthy infants. Multiple linear regressions examined the association of factor scores with group, gestational age, and physiologic variables. Results: 5-factor solution: 1 (Orienting Reflex), 2 (Extensor Axial Tone), 3 (Primitive Reflexes), 4 (Flexor Tone), 5 (Reflexive Tone Around Extremity Joints). Moderate to strong evidence supported: face, discriminant, and construct validity of these factors, with Factor 2 having the strongest. Conclusions: Components of Factor 2 may provide similar information about neonatal development, thus reducing the time for and burden of administration for researchers and clinicians.

Assessment of the cutaneous trunci muscle reflex in healthy cats: comparison of results acquired by clinicians and cat owners.

OBJECTIVES: The study aimed to evaluate the cutaneous trunci muscle reflex (CTMR) in healthy cats using methods performed by the clinician and the cat's owner at home. METHODS: A total of 55 healthy cats without neurological abnormalities were included in this study. CTMR evaluation was performed sequentially in each cat using three methods by a clinician: method A, pinch skin with a straight 14 cm Crile haemostat forceps; method B, displace fur with the tip of a pen or haemostat forceps; and method C, poke skin with the tip of a straightened paper clip. The normal response rates for each method were obtained and compared. A 'CTMR performance score' was assigned for each cat, reflecting the presence of a normal CTMR response using one or more of the three methods. An 'owner performance score' was also obtained, reflecting the response of the CTMR when performed at home by the cat owner. The two scores were compared as paired data for each cat. RESULTS: The CTMR was elicited normally in 17 (31%), 27 (49%) and 16 (29%) cats using methods A, B and C, respectively. Method B delivered a significantly higher percentage of normal responses. When comparing the 'CTMR performance score' and 'owner performance score', the percentage of normal responses was 60% and 100%, respectively, which was significantly different. CONCLUSIONS AND RELEVANCE: The overall normal response rate of the CTMR in healthy feline subjects was low when performed by a clinician, regardless of the method applied. Conversely, a high percentage of normal responses was obtained by cat owners performing CTMR at home, potentially indicating the impact of stress on the CTMR performance.

Spasm of Near Reflex: Objective Assessment of the Near-Triad.

Purpose: To characterize binocular steady-state accommodation, pupil and convergence responses (near triad) in spasm of near reflex (SNR) before and after optical and pharmacological intervention. To identify the putative source of SNR in the neural control schema of accommodation-vergence interaction using controls-engineering modeling. Methods: Near-triad of 15 patients with SNR (9 to 23 years) was recorded using an infrared photorefractor at 2m viewing distance for 120s during clinical presentation, after optical fogging intended to relieve spasm, with cycloplegia, post-cycloplegia and long-term follow-up visits. Data were also collected without cycloplegia in 15 age-matched controls. Schor (1999) model was used to computationally simulate accommodation and vergence responses of controls and SNR. Results: Both eyes of SNR exhibited significant myopia and refraction fluctuations (<1.0Hz) during clinical presentation [median (25th to 75th IQR) refraction: -1.7D (-3.2 to -0.8D); root mean squared (RMS) deviation: 1.1D (0.5 to 1.5D)], relative to controls [0.8D (-0.03 to 1.4D); 0.2D (0.1 to 0.3D)] (p < 0.001). These decreased after optical fogging, largely eliminated with cycloplegia and partially re-appeared in the post-cycloplegia and follow-up visits. SNR responses could be modeled by increasing the gain and decay time of tonic accommodation, vis-à-vis, controls. Pupil and convergence responses in SNR were similar to controls at all visits (p > 0.1). Conclusions: Exaggerated fluctuations of steady-state accommodation may be a signature feature of SNR, even while their pupil and convergence responses may remain unaffected. These fluctuations may arise from the tonic accommodation controller, the properties of which could be potentially altered after optical fogging to relieve the disorder.

Assessment of the cutaneous trunci muscle reflex in neurologically abnormal cats.

OBJECTIVES: The aim of this study was to evaluate the presence of the cutaneous trunci reflex (CTR) in a population of neurologically abnormal cats in regard to age, body condition score (BCS), sex, breed, evidence of traumatic injury, pain, known metabolic disease, mentation, neurolocalization and diagnostic classification. METHODS: A retrospective medical record review was performed to identify cats with a history of neurologic disease undergoing a complete neurologic assessment between 24 September 2012 and 20 March 2019. CTR outcome (present, absent), signalment, evidence of traumatic injury, pain, known metabolic disease, mentation, neurolocalization and diagnostic classification were recorded. RESULTS: A total of 182 cats were identified. The CTR was present in 118 cats (64.8%) and absent in 64 cats (35.2%). Statistical analysis revealed no association between CTR outcome and age, BCS, sex, breed, evidence of traumatic injury, non-spinal pain, known metabolic disease, mentation, neurolocalization or diagnostic classification. A significant association was found between spinal pain and CTR outcome (P = 0.037). CONCLUSIONS AND RELEVANCE: These findings suggest that elicitation of the CTR in the cat can be unreliable. Further prospective controlled studies are warranted to determine whether continued inclusion of the CTR in feline neurologic examinations is justified. Consideration of the reliability of the CTR is indicated, particularly in the context of fractious or anxious patients for which only a limited window for examination may be present.

The assessment of the peak of reflex cough in subjects with acquired brain injury and tracheostomy and healthy controls.

INTRODUCTION: There is no standard procedure to evaluated the peak of reflex cough flow (PCF-reflex) in the literature, which is important assessment in subjects with acquired brain injury and tracheostomy cannula. The present study aims to investigate the PCF of the reflex cough in a broad sample of healthy controls and, furthermore, the presence and the strength of voluntary and reflex cough in subjects with ABI with tracheostomy cannula. MATERIALS AND METHODS: We recruited 147 participants including the healthy subjects (n = 105) and acquired brain injury subjects (n = 43), who underwent respiratory assessment: the Tidal Volume, Forced Vital Capacity, PCF of voluntary cough (PCF-voluntary) and PCF-reflex (using a spirometer connected with a nebulizer by a bidirectional). RESULTS: The PCF-reflex of controls and subjects was significant lower than the PCF-voluntary (P < 0.01). The PCF-voluntary was not assessed in 26 (60.5 %) subjects due to severe cognitive deficit. In subjects without cognitive deficits (n = 17; 39.5 %), it was significantly lower than in healthy controls (p < 0.01). In contrast, the PCF-reflex was completed in all subjects and it was not significantly different from healthy controls. Furthermore, the strength of the PCF-reflex decreased with increasing inhalation numbers of nebulised air. CONCLUSION: Reflex cough behaviour differs largely from voluntary cough and the PCF results reflect this great discrepancy. PCF-reflex could be useful parameter for assessing the airway protection whereas PCF-voluntary for measuring airway clearance.

Quantitative Assessment of Anti-Gravity Reflexes to Evaluate Vestibular Dysfunction in Rats.

The tail-lift reflex and the air-righting reflex are anti-gravity reflexes in rats that depend on vestibular function. To obtain objective and quantitative measures of performance, we recorded these reflexes with slow-motion video in two experiments. In the first experiment, vestibular dysfunction was elicited by acute exposure to 0 (control), 400, 600, or 1000 mg/kg of 3,3'-iminodipropionitrile (IDPN), which causes dose-dependent hair cell degeneration. In the second, rats were exposed to sub-chronic IDPN in the drinking water for 0 (control), 4, or 8 weeks; this causes reversible or irreversible loss of vestibular function depending on exposure time. In the tail-lift test, we obtained the minimum angle defined during the lift and descent maneuver by the nose, the back of the neck, and the base of the tail. In the air-righting test, we obtained the time to right the head. We also obtained vestibular dysfunction ratings (VDRs) using a previously validated behavioral test battery. Each measure, VDR, tail-lift angle, and air-righting time demonstrated dose-dependent loss of vestibular function after acute IDPN and time-dependent loss of vestibular function after sub-chronic IDPN. All measures showed high correlations between each other, and maximal correlation coefficients were found between VDRs and tail-lift angles. In scanning electron microscopy evaluation of the vestibular sensory epithelia, the utricle and the saccule showed diverse pathological outcomes, suggesting that they have a different role in these reflexes. We conclude that these anti-gravity reflexes provide useful objective and quantitative measures of vestibular function in rats that are open to further development.

Simultaneous assessment of central and peripheral chemoreflex regulation of muscle sympathetic nerve activity and ventilation in healthy young men.

KEY POINTS: Central chemoreceptor stimulation, by hypercapnia (acidosis), and peripheral, by hypoxia plus hypercapnia, evoke reflex increases in ventilation and sympathetic outflow. The assumption that central or peripheral chemoreceptor-mediated sympathetic activation elicited when PCO2 increases parallels concurrent ventilatory responses is unproven. Applying a modified rebreathing protocol that equilibrates central and peripheral chemoreceptor PCO2 whilst clamping O2 tension at either hypoxic or hyperoxic concentrations, the independent ventilatory and muscle sympathetic stimulus-response properties of the central and peripheral chemoreflexes were quantified and compared in young men. The novel findings were that ventilatory and sympathetic responses to central and peripheral chemoreflex stimulation are initiated at similar PCO2 recruitment thresholds but individual specific sympathetic responsiveness cannot be predicted from the ventilatory sensitivities of either chemoreceptor reflex. Such findings in young men, if replicated in heart failure or hypertension, should temper present enthusiasm for trials targeting the peripheral chemoreflex based solely on ventilatory responsiveness to non-specific chemoreceptor stimulation. ABSTRACT: In humans, stimulation of peripheral or central chemoreceptor reflexes is assumed to evoke equivalent ventilatory and sympathetic responses. We evaluated whether central or peripheral chemoreceptor-mediated sympathetic activation elicited by increases in CO2 tension ( PCO2 ) parallels concurrent ventilatory responses. Twelve healthy young men performed a modified rebreathing protocol designed to equilibrate central and peripheral chemoreceptor PCO2 tensions with end-tidal PCO2 ( PETCO2 ) at two isoxic end-tidal PO2 ( PETO2 ) such that central responses can be segregated, by hyperoxia, from the net response (hypoxia minus hyperoxia). Ventilation and muscle sympathetic nerve activity (MSNA) were recorded continuously during rebreathing at isoxic PETO2 of 150 and 50 mmHg. During rebreathing, the PETCO2 values at which ventilation (L min-1 ) and total MSNA (units) began to rise were identified ( PETCO2 recruitment thresholds) and their slopes above the recruitment threshold were determined (sensitivity). The central chemoreflex recruitment threshold for ventilation (46 ± 3 mmHg) and MSNA (45 ± 4 mmHg) did not differ (P = 0.55) and slopes were 2.3 ± 0.9 L min-1  mmHg-1 and 2.1 ± 1.5 units mmHg-1 , respectively. The peripheral chemoreflex recruitment thresholds, at 41 ± 3 mmHg for both ventilation and MSNA were lower (P < 0.05) compared to the central chemoreflex recruitment thresholds. Peripheral chemoreflex sensitivity was 1.7 ± 0.1 L min-1  mmHg-1 for ventilation and 2.9 ± 2.6 units mmHg-1 for MSNA. There was no relationship between the ventilatory and MSNA sensitivity for either the central (r2  = 0.01, P = 0.76) or peripheral (r2  = 0.01, P = 0.73) chemoreflex. In healthy young men, ventilatory and sympathetic responses to central and peripheral chemoreceptor reflex stimulation are initiated at similar PETCO2 recruitment thresholds but individual ventilatory responsiveness does not predict sympathetic sensitivities of either chemoreflex.

Autonomic symptom burden is an independent contributor to multiple sclerosis related fatigue.

OBJECTIVES: To investigate a possible association between autonomic dysfunction and fatigue in people with multiple sclerosis. METHODS: In 70 people with multiple sclerosis early in the disease course (51 females, mean age 33.8 ± 9.1), quantitative sudomotor axon reflex tests, cardiovascular reflex tests (heart rate and blood pressure responses to the Valsalva maneuver and heart rate response to deep breathing), and the tilt table test were performed. Participants completed the Composite Autonomic Symptom Score 31, the Modified Fatigue Impact Scale, and the Epworth Sleepiness Scale, as well as the Beck Depression Inventory. Cutoff scores of ≥ 38 or ≥ 45 on the Modified Fatigue Impact Scale were used to stratify patients into a fatigued subgroup (N = 17 or N = 9, respectively). RESULTS: We found clear associations between fatigue and scores in subjective tests of the autonomic nervous system: fatigued patients scored significantly worse on Composite Autonomic Symptom Score 31, and there was a strong correlation between the Modified Fatigue Impact Scale and the Composite Autonomic Symptom Score 31 (rs = 0.607, p < 0.001). On the other hand, we found only modest associations between fatigue and scores in objective tests of the autonomic nervous system: there was a clear trend for lower sweating outputs at all measured sites, which reached statistical significance for the distal leg and foot. We found weak correlations between the Modified Fatigue Impact Scale and the Valsalva ratio (rs = - 0.306, p = 0.011), as well as between the Modified Fatigue Impact Scale and quantitative sudomotor axon reflex tests of the forearm, proximal, and distal lower leg (rs = - 0.379, p = 0.003; rs = - 0.356, p = 0.005; and rs = - 0.345, p = 0.006, respectively). A multiple regression model showed that the Composite Autonomic Symptom Score 31, Beck Depression Inventory, and Epworth Sleepiness Scale were independent predictors of fatigue (p = 0.005, p = 0.019, and p = 0.010, respectively). CONCLUSION: These results suggest that-even early in the course of the disease-people with multiple sclerosis suffer from objective and subjective impairments of the autonomic nervous system. The results also point to an association between autonomic nervous system impairment and multiple sclerosis related fatigue.

Behavioral and Physiological Signs for Pain Assessment in Preterm and Term Neonates During a Nociception-Specific Response: A Systematic Review.

BACKGROUND/GOAL: Assessment and treatment of neonatal pain is difficult because current scales are rarely validated against brain-based evidence. We sought to systematically evaluate published evidence to extract validation of the most promising markers of neonatal pain. METHODS: We searched four databases using germane MeSH terms. We focused on assessments of pain and/or nociception that had at least two measures among behavioral, physiological, or cortical components in preterm and/or term neonates. We evaluated studies for quality of evidence and strength of recommendations using standardized tools. RESULTS: Fifteen articles met our inclusion criteria. Among the behavioral components uncovered in this review, the withdrawal reflex and changes in facial expression are the most strongly associated with nociception-specific brain activity. These associations may be influenced by gestational age and change over time. Physiological signs, such heart rate and oxygen saturation, have little to no association with this type of response. CONCLUSIONS: Current assessments of neonatal pain include behavioral components that are associated with nociceptive processing, but also other less valid components, while omitting newer measures based on neuroscientific research.

Validity and reliability of smartphone applications for clinical assessment of the neuromusculoskeletal system.

INTRODUCTION: Clinicians increasingly use smartphone medical applications. There is no evidence to support the validity and reliability of applications used to assess the neuromusculoskeletal system. The aim of this study was to systematically review the quality of studies as well as the validity and reliability of using a smartphone as a clinical assessment tool for the neuromusculoskeletal system. Areas covered: PubMed, CINAHL and Embase were searched. A manual search was also conducted. Additionally, forward snowballing of relevant articles was performed in Scopus and Web of Science. Two reviewers independently selected the articles, extracted the data using a standardized form and assessed the articles quality based on a scoring system Expert commentary: Thirty-four articles were found eligible and were categorized into four groups: Range of Motion (ROM), posture and deformity, tremors and reflexes, and gait and mobility. Only the ROM category supported the validity and reliability of using smartphone applications as assessment tools. Regarding quality assessment scores, the articles in ROM and posture and deformity categories ranged from poor to good quality, whereas those in the tremors and reflexes and gait and mobility categories had poor quality.

Multi-Domain Assessment of Autonomic Function in Spinal Cord Injury Using a Modified Autonomic Reflex Screen.

The aim of this study was to characterize autonomic lesions in participants with spinal cord injury (SCI; n = 10) using an autonomic reflex screen, incorporating sudomotor, cardiovagal, and sympathetic adrenergic tests, as well as hemodynamic responses to head-up tilt (HUT). Hemodynamic responses were compared to healthy controls (n = 20) and previously published normative cutoffs in order better identify autonomic impairments. Sympathetic skin responses (SSRs), heart rate response to deep breathing (HRDB), and heart rate and beat-to-beat blood pressure responses to Valsalva maneuver (VM) and HUT were measured. SCI participants demonstrated impairment in at least one domain, with 7 of 10 demonstrating autonomic impairment across all domains. No single test was concordant with orthostatic hypotension on HUT, in all participants. Measures of cardiovagal function, including HRDB (SCI = 7.7 ± 3.8 beats/min vs. controls = 17.6 ± 8.1 beats/min) and Valsalva ratio (SCI = 1.53 ± 0.29 vs. controls = 1.85 ± 0.37), were significantly reduced in SCI participants, compared to controls (p < 0.05). These findings suggest that an autonomic reflex screen, which includes standardized testing protocol and normative data for comparison, is useful for determining the autonomic domains affected by the neurological injury in SCI. We also demonstrated significant cardiovagal impairment in SCI participants compared to controls, which warrants further investigation to determine whether cardiovagal dysfunction is associated with the negative cardiovascular outcomes, which are known to occur in SCI.

Cortical and spinal assessment - a comparative study using encephalography and the nociceptive withdrawal reflex.

BACKGROUND: Standardized objective methods to assess the analgesic effects of opioids, enable identification of underlying mechanisms of drug actions in the central nervous system. Opioids may exert their effect on both cortical and spinal levels. In this study actions of morphine at both levels were investigated, followed by analysis of a possible correlation between the cortical processing and spinal transmission. METHODS: The study was conducted after a double-blinded, two-way crossover design in thirty-nine healthy participants. Each participant received 30mg morphine or placebo as oral solution in randomized order. The electroencephalogram (EEG) was recorded during rest and during immersion of the hand into ice-water. Electrical stimulation of the sole of the foot was used to elicit the nociceptive withdrawal reflex and the reflex amplitude was recorded. RESULTS: Data from thirty subjects was included in the data analysis. There was no change in the activity in resting EEG (P>0.05) after morphine administration as compared to placebo. During cold pressor stimulation, morphine significantly lowered the relative activity in the delta (1-4Hz) band (P=0.03) and increased the activity in the alpha (8-12Hz) band (P=0.001) as compared to placebo. The reflex amplitudes significantly decreased after morphine administration (P=0.047) as compared to placebo. There was no correlation between individual EEG changes during cold pressor stimulation and the decrease in the reflex amplitude after morphine administration (P>0.05). CONCLUSIONS: Cold pressor EEG and the nociceptive reflex were more sensitive to morphine analgesia than resting EEG and can be used as standardized objective methods to assess opioid effects. However, no correlation between the analgesic effect of morphine on the spinal and cortical assessments could be demonstrated.

Electrophysiological assessment of nociception in patients with Parkinson's disease: A multi-methods approach.

OBJECTIVE: Nociceptive abnormalities indicating increased pain sensitivity have been reported in patients with Parkinson's disease (PD). The disturbances are mostly responsive to dopaminergic (DA) treatment; yet, there are conflicting results. The objective of the present study was to investigate pain processing and nociception in PD patients in a more comprehensive manner than previous studies. For this purpose, a multi-methods approach was used in order to monitor different levels of the central nervous system (spinal, subcortical-vegetative, cortical). METHODS: The heat-pain threshold, contact-heat evoked brain potentials (CHEPs) and sympathetic skin responses (SSR), nociceptive flexion responses (NFR) and subjective pain ratings were measured in 23 idiopathic PD patients both in the Off-phase (without DA medication) and On-phase (after DA medication intake) as well as in 23 healthy controls. RESULTS: Compared to controls, PD patients showed decreased heat-pain thresholds only in the Off and tentatively increased NFR amplitudes in both phases. We found no between-group differences for the CHEPs, the NFR threshold/latency or the pain ratings. Yet, SSR amplitudes/frequencies were decreased and latencies were increased in PD patients in both phases. Correlations between CHEPs amplitudes and pain ratings were found only in controls. DISCUSSION: Increased pain sensitivity (heat-pain threshold) in the Off which normalizes in the On argues for DA induced dysfunctions of the nigrostriatal pain loops with the basal ganglia as main circuit in our PD sample. Dysfunctions of the subcortical-vegetative parameters despite of inconspicuous cortical nociception suggest disturbances of the central or peripheral innervation of sympathetic branches with coincidently intact ascending pathways in the PD group.

Assessing Auditory Processing Abilities in Typically Developing School-Aged Children.

BACKGROUND: Large discrepancies exist in the literature regarding definition, diagnostic criteria, and appropriate assessment for auditory processing disorder (APD). Therefore, a battery of tests with normative data is needed. PURPOSE: The purpose of this study is to collect normative data on a variety of tests for APD on children aged 7-12 yr, and to examine effects of outside factors on test performance. RESEARCH DESIGN: Children aged 7-12 yr with normal hearing, speech and language abilities, cognition, and attention were recruited for participation in this normative data collection. STUDY SAMPLE: One hundred and forty-seven children were recruited using flyers and word of mouth. Of the participants recruited, 137 children qualified for the study. Participants attended schools located in areas that varied in terms of socioeconomic status, and resided in six different states. DATA COLLECTION AND ANALYSIS: Audiological testing included a hearing screening (15 dB HL from 250 to 8000 Hz), word recognition testing, tympanometry, ipsilateral and contralateral reflexes, and transient-evoked otoacoustic emissions. The language, nonverbal IQ, phonological processing, and attention skills of each participant were screened using the Clinical Evaluation of Language Fundamentals-4 Screener, Test of Nonverbal Intelligence, Comprehensive Test of Phonological Processing, and Integrated Visual and Auditory-Continuous Performance Test, respectively. The behavioral APD battery included the following tests: Dichotic Digits Test, Frequency Pattern Test, Duration Pattern Test, Random Gap Detection Test, Compressed and Reverberated Words Test, Auditory Figure Ground (signal-to-noise ratio of +8 and +0), and Listening in Spatialized Noise-Sentences Test. Mean scores and standard deviations of each test were calculated, and analysis of variance tests were used to determine effects of factors such as gender, handedness, and birth history on each test. RESULTS: Normative data tables for the test battery were created for the following age groups: 7- and 8-yr-olds (n = 49), 9- and 10-yr-olds (n = 40), and 11- and 12-yr-olds (n = 48). No significant effects were seen for gender or handedness on any of the measures. CONCLUSIONS: The data collected in this study are appropriate for use in clinical diagnosis of APD. Use of a low-linguistically loaded core battery with the addition of more language-based tests, when language abilities are known, can provide a well-rounded picture of a child's auditory processing abilities. Screening for language, phonological processing, attention, and cognitive level can provide more information regarding a diagnosis of APD, determine appropriateness of the test battery for the individual child, and may assist with making recommendations or referrals. It is important to use a multidisciplinary approach in the diagnosis and treatment of APD due to the high likelihood of comorbidity with other language, learning, or attention deficits. Although children with other diagnoses may be tested for APD, it is important to establish previously made diagnoses before testing to aid in appropriate test selection and recommendations.

Quantitative assessment of integrated phrenic nerve activity.

Integrated electrical activity in the phrenic nerve is commonly used to assess within-animal changes in phrenic motor output. Because of concerns regarding the consistency of nerve recordings, activity is most often expressed as a percent change from baseline values. However, absolute values of nerve activity are necessary to assess the impact of neural injury or disease on phrenic motor output. To date, no systematic evaluations of the repeatability/reliability have been made among animals when phrenic recordings are performed by an experienced investigator using standardized methods. We performed a meta-analysis of studies reporting integrated phrenic nerve activity in many rat groups by the same experienced investigator; comparisons were made during baseline and maximal chemoreceptor stimulation in 14 wild-type Harlan and 14 Taconic Sprague Dawley groups, and in 3 pre-symptomatic and 11 end-stage SOD1(G93A) Taconic rat groups (an ALS model). Meta-analysis results indicate: (1) consistent measurements of integrated phrenic activity in each sub-strain of wild-type rats; (2) with bilateral nerve recordings, left-to-right integrated phrenic activity ratios are ∼1.0; and (3) consistently reduced activity in end-stage SOD1(G93A) rats. Thus, with appropriate precautions, integrated phrenic nerve activity enables robust, quantitative comparisons among nerves or experimental groups, including differences caused by neuromuscular disease.

Garnett Passe and the tonsillectomy gag.

Kevin Kane has written about the painting by Barbara Hepworth of Garnett Passe performing a tonsillectomy, and wondered about the way in which the gag appears to be suspended. This article traces historically the various methods of holding the gag for tonsillectomy, and postulates that what is illustrated in the Hepworth painting is a jack owned by the late Dr Sydney Cocks, who not only was a friend of Passe but who also commenced the discussions with Passe's widow, Barbara, concerning the formation by her of a trust to support young Australian ENT surgeons, which eventually became The Garnett Passe and Rodney Williams Memorial Foundation.

Methods for assessment of trunk stabilization, a systematic review.

Trunk stabilization is achieved differently in patients with low back pain compared to healthy controls. Many methods exist to assess trunk stabilization but not all measure the contributions of intrinsic stiffness and reflexes simultaneously. This may pose a threat to the quality/validity of the study and might lead to misinterpretation of the results. The aim of this study was to provide a critical review of previously published methods for studying trunk stabilization in relation to low back pain (LBP). We primarily aimed to assess their construct validity to which end we defined a theoretical framework operationalized in a set of methodological criteria which would allow to identify the contributions of intrinsic stiffness and reflexes simultaneously. In addition, the clinimetric properties of the methods were evaluated. A total of 133 articles were included from which four main categories of methods were defined; upper limb (un)loading, moving platform, unloading and loading. Fifty of the 133 selected articles complied with all the criteria of the theoretical framework, but only four articles provided information about reliability and/or measurement error of methods to assess trunk stabilization with test-retest reliability ranging from poor (ICC 0) to moderate (ICC 0.72). When aiming to assess trunk stabilization with system identification, we propose a perturbation method where the trunk is studied in isolation, the perturbation is unpredictable, force controlled, directly applied to the upper body, completely known and results in small fluctuations around the working point.