A Neurological Approach to Speech Therapy for the Cerebral Palsied by RUTH JACOBS. B.A.Log.(RancL) This new approach, which has revolu- tionised speech therapy for the Cerebral Pal- sied child, is based on Neurophysiology. Un- like lesions of the lower motor neuron which cause paralysis, the brain damage resulting in Cerebral Palsy will lead to abnormalities of muscle tone which can produce inco- ordination of muscles, so that the patient is unable to control his muscle function in the normal way. It is because of the abnormali- ties in muscle tone, as welluas the dominance of primitive reflexes, and the absence of higher postural reflexes that normal posture and therefore, normal movements are impos- sible for these children. The peripheral ner- vous system is intact and the power in the muscles necessary for performing movements is there, but the child is unable to direct or grade the impulses in order to obtain smooth and separate movements. It is not possible for the child to contract or relax individual muscle groups, nor to move parts of the body independently. The disorder of motor func- tion is often associated with defects of speech and hearing. The treatment is based on in- hibition of abnormal reflexes and normalising of muscle tone. These are the pre-requisites for normal movement patterns. It is this which allows the maintenance of posture against gravity and also for easy, smooth and purposeful movements. The speech therapist's aim is to give the child the normal sensations of speech, so that she will have to break down and prevent any abnormal reactions associated with the act of articulation. In order to do this the child must be positioned so that the normal speech developmental sequences can be fol- lowed. It must be remembered that as the speech musculature obeys the same laws as the skeleton muscles, the child must be treated as a whole. It is because of the ab- normal and fluctuating muscle tone and lack of grading of movements that the athetoid has involuntary movements. This is seen in the twitching lips and snake-like movements of the tongue. The muscle tone must be steady before one can expect the smooth movements required for speech. In the floppy athetoid one might have to increase tone, being careful not to get spasms — this is done by grading of stimuli. In the spastic, the problem is often one of hypertonicity, and here one must reduce muscle tone by inhibiting the action of the agonists, and where there is co-contraction, of the antago- nists as well. When speaking of reducing muscle tone we refer to that of the whole body. Next, any primitive, pathological reflexes, affecting the speech mechanism must be in- hibited and at the same time higher reflex activity must be introduced, for example: If the child has the bite reflex, and bites when- ever the inside of the mouth is stimulated, desensitise this area and then encourage chewing movements. Speech must function as an activity, inde- pendent from the rest of the body. This means that the child must be able to talk without associated reactions occuring or spasms being initiated. It is true that move- ment and speech go together, but here the grading is important. Stimuli must be care- fully graded so that the child is neither un- der· nor over-stimulated. When encouraging a child to talk, see that the situation is interesting and if you want a certain word, instead of demanding this, talk to and ques- tion the child in order to get him to say the required word. In order to develop speech we must give the child the normal sensation of speaking as χ he learns through sensory intake. It is un- realistic to expect a child to be able to pro- duce sounds unless he has experienced the feeling kinaesthetically, so that no amount of visual or auditory aids will be of assis- tance unless the child is given the oppor- tunity to acquire these normal sensations. Thereafter, one can use these different avenues to re-inforce what has been facili- tated. 2 JOURNAL OF THE SOUTH AFRICAN L O O P E D I C SOCIETY 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Let us now examine the pre-requisites for speech. Firstly, one must ascertain that the child's hearing is adequate for speech. A hearing assessment is, therefore, one of our initial tasks, and must be carried out as early as possible. Here one must ascertain that the baby is at a maturation level in keeping with his age, allowing for the usual lee-way in maturing found in all children. When carry- ing out these hearing tests, be sure that the child cannot only hear, but can localise the sound source. As there is often a high-fre- quency loss associated with athetosis, these children should be very carefully assessed and the possibility of a hearing aid discussed. The testing of these children, particularly those under the age of five, presents many added difficulties, for often their physical handicap prevents a response. In such cases, one must observe the child and use any re- action he can produce. Example: Some babies respond by blinking, others by stilling; the older child may only be able to protrude his tongue and this response must then be con- ditioned so that testing can be carried out. As speech is superimposed on the basic functions, feeding must precede speech, so that a knowledge of the Gesell norms is re- quired. Here again the therapist must remem- ber that these developmental stages are sub- ject to individual variation, and that this variation will depend on the severity of the physical handicaps. At 8-12 weeks when tongue-tip movement should have developed, this will often only occur during a spasm. At 16 weeks, when biting occurs, the Cerebral Palsied child is often not yet able to bite or presents the biting reflex and will bite when- ever the inside of the mouth, and especially the molar area, is stimulated, so that chew- ing is prevented. To inhibit this reflex, hold the jaw open and stimulate the inside of the mouth by rubbing with your finger, or a wooden spatula or spoon if the reflex is very strong. At 28 weeks the baby is chewing and eating semi-solids which it can take from a spoon; it [will be found that many Cerebral Palsied children cannot yet chew at this stage, nor can they purse their lips in order to take food from a spoon. At 40 weeks the baby can hold his own bottle and here again we find that many Cerebral Palsied babies have not iyet reached this stage as they can- not bring their fingers to their mouth, nor their hands to the mid-position. At this stage the child is able to keep his mouth closed and dribbling ceases, but this is long delayed in a Cerebral Palsied child. Another stage which is delayed is drinking from a cup, which the 48 week old child does, although still spilling. Here, the difficulty in mouth closure will mean that liquid escapes down the corner of the mouth. At the end of the first year, the normal child has learned that in order to drain his cup, his head must tilt back. Often flexor spasm prevents the Cere- bral Palsied child from so doing. Should the child have extensor spasms swallowing will be difficult. So through all the remaining stages, leading to self-feeding of a full diet, we will see a delay in most Cerebral Palsied children. The feeding patterns must be care- fully assessed so that, by positioning the head, neck, trunk and limbs we can inhibit the pathological reflexes and prevent spasms, and so progress to a later stage in our de- velopmental sequence. In the same way as we compare the feed- ing stage at which the child is, so too must we watch the sucking and see at what stage of development the child is. At 16 weeks the normal child, when presented with food, opens his mouth, waits for the teat and closes its mouth around it. During the suck- ing movement the posterior part of the tongue is elevated. If solids are introduced at this stage, the baby will make chewing move- ments with his tongue, as he would for suck- ing. Poor sucking movements are usually as- sociated with the following:— (a) the tongue cleaving to the roof of the mouth; (b) imper- fect approximation of the lips; (c) drawing in of the lower lip; (d) inability to release the teat as the child cannot part his lips; and (e) choking and swallowing air as breathing and swallowing are not synchronised. As voice is dependent on breathing we must examine the breathing pattern exhibi- ted by the child and note any existing ab- normalities. Note any blocking on inspiration or expiration. Often it will be seen that the athetoid will breathe in, then block and with great effort get out one word and then the breath supply is finished. Breathing must be automatic, and once a rhythmic pattern is obtained, speech can be superimposed. Begin with vocalisation and aid this by vibrating on the chest wall, larynx, abdomen and spine. It must be borne in mind that movements of the head and neck influence breathing, so that Reflex Inhibiting Postures (R.I.P's) must December, 1962 JOURNAL OF THE SOUTH AFRICAN L O O P E D I C SOCIETY R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) be used and head control facilitated. These Reflex Inhibiting Postures are positions which favour more normal muscle tone and which break up primitive reflex postural pat- terns and. therefore, reduce spasm and spas- ticity. In the case of the athetoid and the ataxic, R.I.P's give stability and are used preventatively. Our emphasis is on expira- tion, for once this occurs adequately, inspira- tion must follow. The voice of the child will supply information as to the breathing. If blocking is noted, the therapist must find where and in what position this occurs. The manner in which one vibrates alters the rhythm of breathing as well as the loudness of the sound, while a change in the position of the head will alter the pitch. Aim at a sustained sound, so that the child will not only get the feeling of breathing out, but will hear his own voice. Once voluntary vocalisa- tion can be obtained, without great effort, babbling can be facilitated. Here the vowels are aimed at first, and as choice is important, it is wise to remember the following: "AH" is an extensor sound and is said with an open mouth. Because of this, it would not be our choice with a child whose pattern was pre- dominantly one of extension as this would re-inforce and not break down the pattern. It is often easier to facilitate the "Ah" sound when the child is in a prone or a sitting posi- tion as this will break down the extensor spasm. As "AU" is also an extensor sound the above holds true. The "OO" sound is a flexion one and the prone position can be favoured. The "OU" sound, while a flexion one, is more difficult to produce as it requires pursing of the lips. The "ER", which is a neutral sound, is a good starting point, When vowels can be produced, consonants are faci- litated by touching the lips and under the chin. The position of the therapist's finger under the chin will raise or lower the tongue in the required position, e.g. place your finger under the chin for "t, d, 1" or "n", so pushing the tongue forward and up. Push further back, so moving the tongue up and back for "k, g" and "ng". Facilitate for "p" and "b" by holding the lips together and then releas- ing them. Often releasing the lips is very difficult for the child. Production of plosives usually increases spasm and this must be watched. When consonants can also be pro- duced, vowel and consonant combinations are worked on. Remember always, that what has been achieved in one position can and must be achieved in other positions. The sen- sory motor- pattern must be laid down for each sound, and the child must progress to as many different positions as possible, the idea being that eventually the child will be able to talk and move without setting up spasms in any part of the body. The criteria for good articulation is a spasm-free trunk and head. With poor head control there can be but little speech. This is seen in a normal child, where, once head control is established, babbling will begin — at about 6 months of age. One cannot have a selective activity without fixation, and as speech is our most selective activity, one cannot expect the intricate speech mecha- nism to function when the head is all over the place. Dribbling and swallowing are also depen- dent on head control. Children dribble be- cause they have not established the skill of obtaining mouth closure, and thus cannot swallow their saliva. One may start working on obtaining mouth closure and facilitating the swallowing reflexfwhile the child is in supine or side-lying positions. However, when the, child progresses to sitting the difficulty in sustaining mouth closure will re- occur where there is poor head-neck and trunk control. If head control can be estab- lished in all positions, dribbling will cease. To dissociate breathing and speech from the posture and movement of the rest of the body we work in R.I.P's initially. In these postures, once the initial struggle has died down, muscle tone.becomes normalised temporarily. Before attempting speech we must be able to place the child in at least one or two R.I.P's. This is because, once muscle tone becomes normalised, proprioceptive sensa- tions can also become normal, so that the speech organs will not only look normal, but will feel normal to the child. In a younger child this position will often induce babbling, or even single words. In older children, where speech has already set up abnormal reac- tions, R.I.P's will reduce spasticity and nor- malise muscle tone so that speech will im- prove. Here, one must facilitate sustained vocalisation and babbling with one's hands, so that the patient makes! no effort. Often these areas which are facilitated must first be desensitised, so that the patient can tolerate the handling. These areas are usually the I JOURNAL OF THE SOUTH AFRICAN L O O P E D I C SOCIETY 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) neck, chest, gums and under the chin. Let us now turn to the assessment of the Cerebral Palsied child. This is the most im- portant item in treatment and should consist of a complete physical assessment, carried out in consultation with a physiotherapist. It is from this assessment that abnormalities will be noted and the therapist will be able to plan her programme accordingly. Re- assessment is equally important, for in this way progress can be noted. From the assess- ment, both abnormal and normal reactions will have been seen and the therapist must decide which are pathological and which primitive, depending on the age of the child. The pathological reactions must be inhibited and then the normal ones encouraged, ad- vancing to higher patterns of co-ordination as the more primitive patterns are replaced. From the assessment the therapist will also see what the child can perform voluntarily and which movements are involuntary, as well as those which can be performed under emotional stress only; e.g. when examining breathing, see if a child can voluntarily hold his breath; can he bite voluntarily or does he only exhibit the bite reflex. It is important to note whether the abnormal, reactions of the child are due to tonic reflex activity, to volun- tary compensation, or, in many cases, to both. During the assessment watch the child carefully and observe what he can and can- not do, and the manner in which, skills are performed. Note the reactions which certain movements will , have on other parts of the body. If the child can speak, listen carefully and assess it generally. As a detailed assessment does not fall within the scope of this paper, suffice it to say that a full assessment of the following must be carefully made:— (a) Sucking. (b) Swallowing. (c) Chewing. (d) Biting.