Non Speech Facilitatory Approaches to CP PDF

FACILITATORY APPROACHES IN THE TREATMENT OF MOTOR SPEECH DISORDERS- SENSORI MOTOR AND NON SPEECH OROMOTOR TECHNIQUES Facilitator y Compensat approach ory es approaches Facilitatory approach  based on the assumption tha...

FACILITATORY APPROACHES IN THE TREATMENT OF MOTOR SPEECH DISORDERS- SENSORI MOTOR AND NON SPEECH OROMOTOR TECHNIQUES Facilitator y Compensat approach ory es approaches Facilitatory approach  based on the assumption that vegetative movements of respiration and feeding underlie movement of speech  assumes that speech can be facilitated by following certain procedures:  Vegetative therapies  Reflex based therapies  Others: motokinesthetic treatment, sensorimotor stimulation of oral structures, oral motor programs with non speech exercises, manipulation techniques (intraoral and extraoral techniques)  believes in improving posture, tone and strength before correcting speech  There is firm belief in improving tone abnormalities through isotonic and isometric exercises. Non speech techniques Nonspeech oral motor treatments (NSOMTs) diverge from phonetic and/or phonemic treatments they target nonspeech motor movements and oral postures with the aim of developing motor patterns requisite for speech sound production NSOMTs employ various exercise movements, instruments such as horns and whistles, and stimulatory techniques. Strode & Chamberlain (1997) Strode & Chamberlain (1997) “Nonspeech oral motor treatment is designed to facilitate development of the motor skills needed for speech sound production through sensorimotor and oral-motor intervention. This enables the child to develop motor skills for speech and motor memory of speech sound productions so he can acquire appropriate movement and placement of the articulators for the target sounds” Assumptions underlying the use of NSOMTs The use of NSOMTs implies that a muscle deficit is the causal factor of developmental sound system disorders The neurophysiology of the limbs and oral musculature is similar, which suggests that therapeutic principles of limb rehabilitation apply to oral rehabilitation There is a transfer of training from the practice of NSOMT tasks to speech tasks  Hodge (2002)  NSOMTs are a collection of stimulation techniques and procedures  designed to influence the resting posture and/or movement of the lips, jaw, and tongue.  Other researchers assert that NSOMTs include specific nonspeech exercises to  (a) increase strength and improve muscle tone and range of motion  (b) modify tongue, lip, and jaw resting postures  (c) improve muscular control and function through sensory stimulation Types of NSOMTs active muscle exercis e pa or ss s i n se y l mu e v u e x s cl i m er e st tion c e is a Clark, 2003 Active Exercises:  The most commonly used intervention technique strength training Stretching Strength training: Strength training programs may use isotonic or isometric muscle exercises. Isotonic exercise movements result in changes of muscle length with muscle tension remaining relatively constant; isometric exercise movements are designed to create muscular tension without changing muscle length appreciably (Clark, 2005). For example..  Isotonic exercise lip pops- might be used to improve lip strength.  In this exercise, the client is instructed to bring the lips together and then open the lips forcefully while making a popping sound. The purpose is to overload the muscles beyond their normal operating levels, through the application of progressive resistance  Isometric exercise  having the client hold a tongue depressor between the lips for a specified period of time with both time and number of trials manipulated. The exercise creates muscular tension without altering muscle length significantly.  Strength training targets force, endurance, and power When a muscle contracts, it generates force or tension, and strength training is designed to increase muscle tension. active exercise also targets endurance, which is the amount of force that can be maintained over a period of time. Finally, active exercise is also conducted for the purpose of developing power, the speed with which force is generated. Stretching: Stretching is the movement of a muscle or muscle group outside of its typical operating range. A corollary to stretching is ROM (Range Of Movement), wherein a muscle or muscle group is moved through its complete range of expected movement, not beyond the range. Stretching exercises are employed to either increase or decrease muscle tone. Clark (2003) pointed out that stretching can be carried out by either the client (active stretching) or the practitioner (passive stretching). During active stretch exercises, muscle fibers may be subject to quick stretching or slow stretching. Quick stretching results in an increase in muscle tone; slow stretching results in an inhibition of the stretch reflex and a corresponding decrease in muscle tone Duffy (1995) suggested that active stretching may have some benefit in reducing spasticity of the articulators when engaging in exercises such as prolonging maximum tongue protrusion, lip retraction, or jaw opening. Passive Exercises: movement of a muscle or muscle group with assistance by a clinician or through the use of exercise machines (Pinet, 1998) includes passive range of motion (PROM) and passive stretch purpose  is not to build muscle strength, but to maintain joint flexibility and soft tissue integrity, enhance vascular circulation, facilitate sensory input to a muscle or muscle group, and possibly modify tone PROM exercises Passive quick for clients who cannot stretches actively exercise designed to stimulate because of severe hyper- muscle spindles, thereby or hypotonicity. increasing muscle tone. It is hypothesized that a The distribution of slow passive stretch acts muscle spindles in the to reduce the stretch oral musculature differs reflex from that of the limbs; seemingly be consequently, the same appropriate in cases of treatment principles of hypertonicity because muscle spindle the goal is to reduce activation or excessive muscle tone. deactivation may only apply to the jaw elevator muscles  Sensory Stimulation:  different sensory stimulation agents that are applied to improve or stimulate muscle function. Typically, sensory agents include the use of massage, vibration, temperature (hot/cold), and electrical stimulation  The different types of input are sensed by a variety of mechanoreceptors, proprioceptors, nociceptors, and thermoreceptors that are responsive to alterations in muscle length and accompanying rate of change in length, muscle tension, joint position, vibration, deep pressure stimulation, skin pressure, two-point discrimination, pain, temperature, and touch (Shelton, 1989).  The incoming sensory or afferent information is processed at different levels of the nervous system, and there is a response by the efferent or motor system.  The sensory agents have different effects on the muscle system such as relaxation, movement or increased range of movement, increased tone, and/or reduction in tone. Massage Clark (2003)  massage may take the form of stroking muscles or tapping muscles. Stroking muscles is carried out for the purpose of reducing muscle tension and creating a state of emotional relaxation It consists of stroking, kneading, and rubbing muscles in preparation for active exercise so that functional performance might be enhanced The sensory stimulation facilitates muscle relaxation and improves local blood flow, pain relief, and muscle suppleness. Massage is not a strength-building technique, nor will it inhibit muscle wasting or hypotonicity  Tapping muscles is used to stimulate the muscle spindle, thus increasing muscle tone  It is done by striking the belly of the intended muscle with the fingertips during active muscle contraction. Brisk tapping may conduct along adjoining bone and stimulate additional muscles that are not targeted. Therefore, tapping does not appear to be an appropriate technique for the oral musculature because of the neurophysiological difference between the limbs and the speech articulators with respect to muscle spindle distribution (Clark, 2003).  Vibration  Vibration is another form of sensory stimulation that is employed in muscular rehabilitation.  The frequency of vibration will either facilitate or inhibit muscle activity  High-frequency vibration stimulates muscle activity; low-frequency vibration inhibits muscle activity  Clark (2003)  high frequency vibration is used to elicit a tonic vibratory response, a reflex contraction that is the result of muscle spindle stimulation.  In addition, there is an accompanying decrease in muscle tone of the antagonist muscle through reciprocal inhibition. Thus, vibration acts to enhance the tone of the agonist and reduce the tone of the antagonist.  However, there are a number of reservations regarding placement  Temperature  Superficial heat is applied to muscles to reduce muscle spasm and spasticity.  The application of heat has not been used extensively with the speech musculature;  however, cold has been used quite frequently in the treatment of persons with neuromuscular disorders (Hall, 2001).  Johnson and Scott (1993)  icing procedures may be used with different populations that include persons with cerebral palsy, acquired neurological insult such as stroke, and progressive neurological disease like multiple sclerosis.  It has been reported that cold acts to reduce spasticity in muscles because it decreases nerve conduction speeds (Clark, 2003).  Shumway-Cook and Woollacott (1995) stated that quick icing of a muscle can facilitate muscle activity, and it may also reduce muscle spasm.  Cold in combination with tactile stimulation has been used regularly in speech-language pathology as a stimulating agent to improve the speed in Electrical stimulation  Electrical stimulation is used in a number of applications for muscular problems, but no extensive history in the speech pathology literature (Clark, 2003).  Humbert and Ludlow (2004) indicated that electrical stimulation can be applied to the skin or directly to muscles via electrodes that are inserted into muscle fibers. When applied to the skin with surface electrodes, electrical stimulation will activate sensory receptors and muscles just below the skin tissue.  Most applications of electrical stimulation involve intramuscular stimulation, with the stimulation controlled by the client or automatically delivered.  Clark (2003) indicated that low-level electrical voltage is applied to muscles for the purpose of stimulating muscle contractions.  She pointed out that the physiological effect of electrical stimulation on various muscle fibers differs from the activation pattern that is found during purposeful exercise.  Furthermore, literature shows that electrical stimulation is most effective when it is used in combination with strength training and/or functional muscular activities. Procedure Problem Type of NSOMT Active Exercise (a) Strength Training Muscle Weakness Overload muscles above normal operating levels; generally using resistance exercises. (b) Stretching Muscle Tone Quick stretching increases muscle tone; Slow stretching decreases muscle tone. Passive Exercise Muscle tone, joint flexibility, Assisted movement of muscle or circulation, sensory input. muscle group. Sensory Stimulation (a) Massage Relaxation of muscles, muscle Stroking muscles, tapping tone. muscles. (b) Vibration Stimulates or inhibits muscle Low or high frequency vibration. activity. Apply heat or cold. (c) Temperature Muscle tone, muscle spasm, sensory deficits, edema, swelling. Apply low-electrical voltage. (d) Electrical Stimulation Muscle movement. Speech facilitation Techniques Can be used as a primary or supplementary technique for the improvement of articulatory skills. Assists in the teaching and learning of articulatory functions through the use of extraoral manipulations and cues, and phonodenatal guides and intraoral cues It creates an awareness of articulatory movements and placements.  Terminologies Stimulator Respondant Manipulations Means skillfull or dextrous treatment by hand. Person applying the extraoral Person responding to Extraoral manipulation, finger the stimulation. manipulations  and hand cues and phonodental guides. provided through prescribed manual movement, timings, pressure exerted on the extraoral speech mechanism.  SPEECH FACILITATION PRINCIPLES Establishment of stimulator-respondent rapport, Teaching of position and movement for each phoneme, Gesture of manipulation should be controlled for optimum rhythm rate pause pressure duration sensory stimuli seating position Addition or exclusion of sensory stimuli. PURPOSE OF SPEECH FACILITATION To clarify and amplify the original instructions for the Moto-kinesthetic stimulations To describe the production and placement of the Speech Facilitation phonodental guides. Moto-kinesthetic method  Sara Stinchfield Hawk and Edna Young (1938) They stressed the development of correct movement patterns and required the clinician to manipulate or stimulate the articulators. Respondent understand the manner in which articulators work individually and in coordination in the production of sounds. stimulation by touch - to develop kinesthetic patterns through movement and pressure. auditory patterns were established simultaneously with the manipulation and that visual cues.  Plastic Palate Phonode ntal Zonds guides Intra Tongue oral Electric al Blades devic Stimulat ion e Intraoral Intraoral Tactile Training Monitori Aid ng System Dillydots  Plastic palates (Gerhardt H. Breckwoldt,1948  The thin plastic sheet exactly fit the hard palate and part of the soft palate.  Magnesium carbonate or powdered sugar - rub the dark inner surface so lingual contact would be revealed.  Measurements of the spaces touched by the tongue provided additional information beyond the visual cues shown by the diagram.  When the sounds were articulated correctly, almost identical patterns were produced by both the client and his clinician.  A Zond- used to force the tongue into a prescribed position for the production of a particular sound   Intraoral tactile and proprioceptive monitoring system  Use of oral stereognosis material, tongue blades or tongue depressors oral stimulators etc.  utilized a therapy program to work with children with defective tactile monitoring systems.  These programs consisted of three phases:  Phase I:  1. Place object in client’s mouth. How are they is it the same or different?  2. Look at the objects; put them back in the mouth  3. Draw a picture of the objects.  Phase II:  1. Stimulate the oral cavity with swabs of cotton going over contact areas  2. Use phonetic placement.  3. Have client make clay model of oral structure; place pegs where contac is made.  Phase III:  1. Stimulate.  2. Discuss points of contact.  Studies have shown that therapy directed at oral sensory training did resu in improvement of defective articulation (Wilhelm, 1966; Ruscello and Las 1972).  Tongue Blades  Used to stimulate intraoral sensitivity.  The tongue blades are used to push back, lower, and curl the edges of the tongue as well as to indicate the point of contact between the tongue and the other articulators. Phonodental guides Objects placed in oral cavity so that the tongue can identify the general articulatory areas for certain sounds.  Orthodontic wire guides  Small knobs added to orthodontic bands as a type of intra oral guide.  EXTRA ORAL MANIPULATION:  The Manipulation models consist of :  (1) A lips format with numbered points (Ringels model)  (2) A finger and hand format, and  (3) A face format with numbered points. Ringels model These numbered models of the lips are placed next to the instructions for the extraoral manipulations in each Stimulation Unit. This model may be used to practice the extraoral manipulations before they are used with respondents.  Finger and Hand Finger and Hand Cues Format  In the manipulations, the following terms are used.The numbering system for the manipulations makes the hands interchangeable. The thumb and middle finger are utilized in the starting position. Other stimulation systems Propriocepti ve Visual- Neuromuscu Auditory lar Cues Facilitation Kinesthetic Cues Techniques Vibrotactile Stimulation Visual tactile aids Thank you..   