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.  

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

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