Physiotherapy on the Airway of Bruxist Children
Condition: Sleep Bruxism; Airway Remodeling; Physical Therapy Modalities
MeSH terms: Bruxism; Sleep Bruxism; Airway Remodeling
Study type: Interventional
Phase: Phase 1/Phase 2

Summary: 
      Objective: to evaluate the effects of physiotherapy on the anteroposterior airway size in a
      group of bruxist children

      Question: Is a physiotherapeutic technique aiming at changing the head posture, effective to
      increase the anteroposterior dimensions of the upper airway in bruxist children?

      Hypothesis: The bruxist children treated with physiotherapy will present higher airway
      dimensions

      Design: randomized clinical trial with allocation and blinding of the examiners.

      Participants: 3 to 6 year old children with complete primary dentition, dental and skeletal
      class I occlusion. The participants were classified as bruxist according to the minimal
      criteria of the ICSD for bruxism. The children were randomized in an experimental (n=13) and
      a control (n=13) group.

      Intervention: A physiotherapeutic intervention using the Awareness through movement technique
      was applied to the children of the experimental group once a week, until 10 sessions were
      completed.

      Outcome measures: anteroposterior measurements of the nasopharynx, oropharynx and hypopharynx
      taken in a lateral cephalogram with standardized techniques.
    

Detailed description: 
      The physiotherapeutic intervention was based on the Awareness Through Movement (ATM) (Goldman
      2003, Malmgren-Olson et al 2001) technique. It is an established method of movement
      re-education where coordination and posture are significant factors. Its proponents believe
      more effective and efficient actions can emerge from guided exploration of movement that
      promotes improved attention and awareness and refines the ability to detect information and
      make perceptual discriminations.

      "Awareness through Movement" (ATM) (Stephens et al 2006) is a process which facilitates the
      learning of strategies for improving organization and coordination of body movement by
      developing spatial and kinesthetic awareness of body-segment relationships at rest and during
      motion, awareness of ease of movement, reducing effort in action, and increasing learning of
      feeling the muscles longer in action and while breathing .

      Ten physiotherapeutic sessions were planed during a ten week period, all of them based in
      children games. Each session lasted three hours.

      The children of the experimental group and their parents were guided by two expert
      physiotherapist previously standardized and the sessions took place in a room rounded by
      mirrors, where the children were able to see their own movements. The parents helped their
      own children during the session and in their home plan indicated weekly.

      Each session pursued the following steps:

        1. Presentation to the parents of the somatic awareness technique for each day.

        2. Movements, games, motor tales and exercises performed by the children, guided by the
           parents and with the guide of the physiotherapists.

        3. In each session, a guide book with cartoons was given to the children and their parents
           to reinforce the exercises at home to keep a long-term result regarding the body and
           head posture. The guide book was designed and created by physiotherapists, teachers and
           advertisers that were not participating in the study.

        4. After the first session, a feedback was given before starting the next session, so the
           exercises at home and the difficulties were reviewed and solved.

      All the children assisted together to all the sessions and the instructions and instruments
      given to the children and their parents were the same for all of them.

      Error of method There were not statistically significant differences, regarding the age of
      the two groups.

      Standardizations of the examiners and calibration of all the techniques to evaluate the
      children regarding the clinical examination and the physiotherapeutic evaluation were made on
      12 subjects different from the ones included in the investigation. The Intratester (ICC> 0.9
      2-way ANOVA) and intertester error (Kappa > 0.7) were not statistically significant.

      A calibration of the x-ray technique and a standardization of the digital tracing of both the
      cephalogram were also performed. The tracing of the cephalogram was standardized between
      three investigators with 5 x-rays, scanned and traced two times each by each of three of the
      investigators. To determine the Intratester and intertester reliability, the intraclass
      correlation coefficient (ICC > 0.3) and Kappa test were applied.

      A lateral cephalogram was taken before and immediately after the 10 session physiotherapeutic
      intervention for each child with the Natural Head Posture technique, described previously by
      different authors (Solow and Tallgren 1976). The technique is reproducible (Siersbaek-Nielsen
      and Solow 1982) and allows the clinician to evaluate the natural position of the cervical
      vertebras and the inclination of the cervical column and head posture.

      Afterwards, the digital record of lateral cephalograms were processed in agree with Sayinsu
      et al 2006, using a program developed under Matlab 5.3 (MathWorks, Inc., MA. USA).
      Anteroposterior measurements of the nasopharynx, oropharynx and hypopharynx were taken in a
      lateral cephalogram with standardized techniques.

      The method error ranged from 0.27 to 0.64 degrees and the coefficients of reliability from
      0.97 to 1.00

      Data analysis The sample size was calculated with a confidence of 95% and a statistical power
      of 80%. The number of subjects required in each group in order to make the comparisons was
      12.

      Distributions were tested using the Shapiro-Wilk test. The data were compared using the Mann
      Whitney and chi square tests. For all tests, significance was set at 5% (p < 0.05).
      Comparisons among and between groups were performed for all the variables (measurements of
      the airway) in order to answer the research question.

      Results: Statistically significant increases were found for the measurements of the
      oropharynx (3 mm increase. 95% CI 0.22 to 0.32) and hypopharynx (3 mm increase 95% CI 0.11 to
      0.20) for the children that received treatment with physiotherapy.

      Conclusion: The physical therapy to change the head posture in bruxist children was useful to
      increase some of the dimensions of the airway in bruxist children.
    

Intervention name(s): Physiotherapy
Intervention type(s): Other
Intervention description(s): The physiotherapeutic intervention was based on the Awareness through Movement technique. Ten sessions were planed. Each session lasted three hours.
The children of the experimental group and their parents were guided by two physiotherapist and the sessions took place in a room rounded by mirrors.
Each session developed as follows: presentation to the parents of the somatic awareness technique for each day; movements, games, motor tales and exercises performed by the children; in each session, a guide book with cartoons was given to the children and their parents to reinforce the exercises at home to keep a long-term result.
All the children assisted together to all the sessions and the instructions and instruments given to the children and their parents were the same for all of them.
Other intervention name(s): Awareness through movement
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Sleep bruxism; Airway remodeling; Physical therapy modalities; Child preschool.