Tagged "Cerebral Palsy"


Ask A Therapist: 24 Year-Old Male With Severe Stuttering

Posted by Deborah Grauzam on

I am a speech-language pathologist in private practice. One of my clients is a 24 year old male with severe stuttering. He also has a diagnosis of mild cerebral palsy. His most noticeable dysfluent behavior is the inability to initiate speech due to blocks at the vocal fold level. Do you think any of the Talk Tools would help? Thank you!

 

Jody

Hi Jody,

According ASHA, most treatment methods for stuttering are centered around behavior; however there are treatment protocols that focus on breathing. This is true of Dr. Martin Schwartz who wrote Stutter No More in 1991 about the "Passive Airflow Technique". For this method  stutterer is taught to 1. Release air 2. Slow down the first syllable and 3. Intent to rest between verbalizations.

Since the goal of Oral Placement Therapy is to provide tactile cues for speech sound production, we would consider OPT tasks that specifically target phonatory control and diaphragmatic breathing if the client was not using proper airflow to support speech. Phonatory tasks such as the horn kit, spirometer or bubble tube could be tools that would assist improved speech breathing; however we would also be certain that we were using more specific evidenced based therapy techniques for stuttering. These methods alone would not directly facilitate fluent speech but rather assist you in the pre-requisite skills needed to engage in airflow methods.

We would try blowing with horns or bubbles or encouraging airflow of any kind on his hand.  Once we felt like he was able to coordinate his breathing and blowing we would then move to humming or adding the "m" sound. We would work on this very gradually.  

Please keep us posted on how it goes and let us know if you have any other questions.

Thanks,

Robyn Merkel-Walsh, MA, CCC-SLP & Elizabeth Smithson, MSP, CCC-SLP
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Ask A Therapist: Feeding Therapy for a Medically Fragile Client

Posted by Deborah Grauzam on

Hello Talktools,

 

First of all, I cannot tell you how much I enjoyed Lori Overland's conference on Feeding Therapy: A Sensory Motor Approach in Savannah! I learned so much and have been able to apply the new (to me) strategies with many of my clients.

 

I have a question for Lori about a challenging client. My overall question is: how long after a frenectomy can we begin working on oral-motor therapy?

 

The client is medically fragile. He has 1/3 of his brain (brain stem, parts of occipital, visual cortex is present). He also suffers from CP and diabetes insipidus among other things. He is adopted, and his parents are EXTREMELY dedicated.

 

He is surprising us all with what he is able to do so far. He will be one year old in a couple of weeks, but he presents like a 3-4 month old right now.

 

He is able to consume liquids with a bottle, but his tongue tie is preventing him from being able to efficiently nurse, and he is gagging on pureed solids. His tongue tie is being corrected by an ENT surgeon this week. However, his mother is concerned because the doctor indicated the "easiest" thing to do would be to put in a peg tube.

 

While this baby is medically fragile, he is making progress in all developmental domains. His mother is realistic about him potentially needing a tube, but wants to make sure he truly has the opportunities to reach his maximum potential.

 

Any suggestions or insights would be welcome! He is very complex, and I know that without your class, I may not have been as prepared for him!

 

Thank YOU!

 

Amy

 

Hi Amy,

Thank you for taking the time to tell me how much you enjoyed the course!

You should be able to begin working on oral-motor therapy with your client within a few days after his frenectomy, but I usually do a two week follow-up, so I can see what the spontaneous results of the surgery will be vs. the impact of the therapy.

It is EXCELLENT to hear that he is surprising you with his abilities and how dedicated his mother is. Reach for the stars, it is nice to be surprised!

In regards to the tongue tie, releasing the tongue will not be a miracle for this little guy, but it will allow you to work on the oral sensory motor skills he needs for feeding. Even if at some point he does need a tube for adequate nutrition, it would be nice for him to do some safe recreational feeding. So...a week to two post-op, start to work on the lateral borders of the tongue, tongue blade stability, and tongue retraction.

I AGREE completely with making sure he has the opportunity to reach his maximum potential!

Good luck and feel free to check in with me if I can help!

Lori Overland, MS, CCC-SLP, C/NDT

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Ask A Therapist: Challenging Patient

Posted by Deborah Grauzam on

Hi TalkTools!

 

I have taken your Three-Part Treatment Plan for Oral Placement Therapy class and have 3 of your books. I am using OPT within my practice and see positive results in my patients. I do have one patient who is very challenging. She is 16 years old, globally delayed and has a diagnosis of cerebral palsy, sensory processing disorder, low cognition and is nonverbal. She loves to eat and does eat a fairly typical diet despite all of this, but of course, can't chew very tough meats. She drools. She has had very little oral motor therapy integrated into her speech therapy treatment plan over the years.

 

I will call my patient, M. We have been working on the bite tube hierarchy following the OPT evaluation, and she is able to compress the bite tubes (red bite tube- 10, bilaterally which is an improvement from where she started;  yellow bite tube- 7 on left and 5 on right- both sides of jaw are weak, but right is weaker). We are about to add purple bite tube when parent is ready. It has also resulted in less mouthing of objects, oral seeking and general calming.

 

M. is hypersensitive to facial touch and having her hair touched. She is also over responsive to some kinds of touch within the mouth despite use of sensory techniques from OPT (sensory program with toothette) and Beckman techniques used for several months. She has shown an improvement to tolerate tooth brushing at home since intervention.

 

1 - M. is using straw #1 on the straw hierarchy, but since it has been systematically cut to 1/4 inch, she is showing an increased jaw movement, which I'm thinking means she is still suckling the straw rather than using a true suck. She is getting better at not placing her lips over built in lip block. She only uses the straw for part of the evening at home with parent supervision, it is not used during the school day, but I might be able to arrange this with school staff. Do you think the reason she is not progressing on straws is that I have cut the straw too short, too soon, or is she just not getting enough practice with it? She likely has been suckling for many years now.

 

2 - I have not had any success using the bubble blowing hierarchy or horn hierarchy or pre-hierarchy horn, even with having a PT present to assist with positioning. She does not appear to understand how to grade her abdominal movements to exhale at all.

 

3 - I would appreciate any guidance you can give me regarding M., as I do want to help her with saliva control. We have had some success increasing her ability to request preferred snacks and activities with the PECS program, since she came to me with no communication system at all. I am about to visit her school to collaborate on her treatment program. Her parents are willing to work on PECS with her at home. They would like for her drooling to decrease, but they are only able to work on straws and bite tubes to a limited degree at home.

 

Thank you for your time.

 

Holly

 

Hi Holly,

Thanks for your question! Allow me to address each of your questions individually to make things easy to follow.

1 - Go back to the 1/2" length to see if she is moving her jaw.  If not, then go to 3/8" as she is 16 years old and may need that amount of the straw to give her enough room to protrude her lips.  The length is not as important as her ability to use only her lips with her tongue retracted and not biting on the straw.  If she can do that without jaw movement, progress to Straw #2 cut to 3/8".

2 - Try working with an OT who can bounce her on a ball to generate airflow.  Once she can do that, you can put the horn in her mouth as she is bouncing down to teach the relationship.  I have also described another technique below that I use with some kids.

Whispered “Huh”

Place the open palm of M's hand 1” in front of your mouth as you say a whispered “huh” sound.  Immediately place M's​ open palm in front of M's​ mouth as you model the whispered “huh” sound.  Continue to alternate between your mouth and M's​ mouth until M tires, refuses the intervention or produces a volitional exhalation.  Reward any attempt at imitation. (Goal:  Associate the feel of airflow on M's​ hand with volitionally controlled oral airflow for speech sound production)

3 - ​It sounds as though you are on the right track with this young girl.  Keep at it as the techniques you are suggesting are the correct ones and you are making progress.  Let the parents know that the horn blowing will be the best treatment for the drooling but that you need them to do the homework at least 3 times a week or it will not work. I hope this answers your question but if not, please let me know how else I can help.

Sara Rosenfeld-Johnson, MS, CCC-SLP

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Ask A Therapist: Dystonic Cerebral Palsy Extension Patterns and Jaw Weakness

Posted by Deborah Grauzam on

Hi there,

I have just assessed an absolutely delightful little four year old boy with a diagnosis of Dystonic Cerebral Palsy. All four limbs are affected but the weakness is more apparent on the right side. My assessment has shown that he presented with significant jaw weakness and instability, he begins to jaw jut and slide after three seconds of trying a natural bite. In addition he has not sufficiently dissociated jaw, lips and tongue muscles. He has weak core muscles and very weak airflow when he speaks. Articulation is mainly open vowels with the occasional gutteral k/g and b produced with the upper teeth on the lower lip.

My main question has to do with his significant extension patterns. Whenever I presented food or a tool to the right side of his mouth it resulted in a huge neck extension round to the right with the left arm extending backwards. He needed his dad to consistently hold his head in midline. When I worked at midline e.g. frontal spoon feeding, horns and bubbles the extensor pattern to the right was still present but not as significant.

I am concerned that by working more on the right side (as I need to do because of his more significant muscle weakness on the right side) this will encourage further extensor patterns. Does anyone have experience of how to deal with this and suggestions on how to effectively work on his right side? I wondered if doing bilateral placement for bite blocks and chewy tubes would be advisable? Many thanks!

Hi and thank you for the question. In commenting, I would like to start with a question.  Is your client working with a PT and if so are they working on the rotation in his trunk?  You may want to work on airflow in rotation if you can cotreat.  One comment that many hear in my course is that "What you see in the body is what you get in the mouth" and this is particularly applicable to your comment about the upper teeth on the lower lip.

For your main question: Is your client in a well supported position when this occurs?  Also, does he have extensor patterns in his upper and lower extremities with any movement? You can also try working from behind (you are actually hip to hip with your upper arm keeping his head in neutral flexion and your fingers providing jaw/lower lip support) using a "v" finger position to support his jaw/lower lip. This will allow you to keep his head in neutral flexion vs extension. I would place a mirror in front of him so he can see himself ...and you.

For your next question: You answered your own question.  I think you should go outside the box and try to present the chewy tubes bilaterally.  I would work on symmetry first and then you may be able to alternate bilateral and unilateral chewy tubes ...so you can work bilaterally and then alternate sides.  Eventually you may be able to do two times right to one time left.  I might do a chew tube program before I introduced the bite block program. I hope this helps and let me know.

Lori Overland

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Ask a Therapist: Developmental Delay and Cerebral Palsy

Posted by Deborah Grauzam on

Hi, I have two clients that I need assistance with.

The first little girl is 5 years old and has developmental delay.  She is mostly non-verbal and communicates using Makaton.  We have used various bits of TalkTools equipment, combined with speech sound work (discrimination and encouragement to imitate single sounds).  So far we have worked through the straw hierarchy (as best we can given her level of understanding) and this has improved tongue retraction.  We have also used tongue depressor with pennies between the lips and she has enough strength to hold 3 pennies on each end without difficulty.  This has improved her lip closure and has stopped her dribbling but we have yet to hear her make any p, b or m sounds.  We have also been using the tubes and bite blocks for vowel sounds but she is still unable to imitate any vowels although can produce some spontaneously.  Her babble has really improved and she is making lots more involuntary vowel and consonant sounds but nothing on cue, and occasional approximation of words in the correct situation.  I have tried to work through the horn hierarchy and the bubble hierarchy but she is unable to blow.  She has just started to wobble the bubble on the wand by vocalizing but I don’t know how to get her to understand how to blow.  Do you have any ideas about where I should go next?

This is a very involved case - I will say that if she can't blow, she can't phonate and you need pre phonatory work to expand the rib cage. You may also need to order the exercises more carefully rather than bits and pieces. For example, sensory tasks such as Lori's mouse ears helps with the feel of the /m/ (see "Feeding Therapy: A Sensory Motor Approach" by Lori Overland).  Next feeding, then Oral Placement Therapy (OPT), then shaping OPT to Speech with Renee Roy Hill's Apraxia Kit.  This is a child who can't respond to "look at me and say what I say" so I'd skip the traditional auditory drills.  It sounds like Apraxia, so you need to be consistent each session and ensure there is true mastery at each level of the hierarchies.

The second little girl is the same age and has cerebral palsy. We have been doing similar things although she is able to make a noise through the horns but is unable to do so without vocalizing at the same time. She is able to blow bubbles well through a small piece of straw but is unable to coordinate her mouth to blow bubbles without physically having the straw in her mouth. Do you have any ideas for how to get around this?

Slowly shape the movement.  For example, 9x using bubble tube 1x without. Make sure they are practicing the best level in therapy at home daily and that the tube is wide enough that the lips are truly rounded - if you need a larger tube use the jaw closure kit. As far as voicing into the horn, that is a motor planning issue.  I usually use modeling, "quiet blowing" and if needed I whisper "hoo" with no voicing to help. These are the same kids that can not turn the voice on either but practice often helps. Make sure there's adequate posture to support the phonation tasks.

Best,

Robyn Merkel-Walsh

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