SEPTEMBER, 1973 P H Y S I O T H E R A P Y Page 7 ] I Speech Therapy Report a b y j. W. PELSER V Speech Therapist at West Rand School for Cerebral Palsied Children, Krtigersdorp “In order to provide enough breath fo r the spoken work, there m ust be enough air intake to have voluntary control of in h alatio n and exhalation.” “ In order to provide sufficient breathing capacity for continuous o r phrased speech a child should be able to sustain an even exhalation fo r a m inim um of ten onds.” 'T h e abovem entioned statem ents by K eats in his books on C erebral Palsy form the basis o f o u r program m e of breathing therapy. A fter having treated dysarthric patients fo r several years, it has become ap p aren t th a t although we h av e achieved im provem ent o f the articu la­ tion of isolated sounds; w ords as well as spontaneous speech still seem to be indistinct and difficult to u n d er­ stand. T his we fo u n d was caused prim arily by b reath ­ ing problem s, as the children did n o t have enough air intake fo r the voluntary control o f inhalation and ex­ halation. I. SELECTION OF CHILDREN FOR THE PROGRAM M E: Eight children were selected. All the candidates had received therapy fo r three years or m ore, w ithout apparent success. T he fo u r boys and four girls chosen, varied in age and degree o f severity o f dysarthria. Case 1— Case 3— Case 2 C ase 8— Case 6— less afflicted _ Case 4— 1 ~ Case 7— > severely handicapped Case 5— J The severe cases had a speech p attern m arked by long shallow inhalation and exhalation im m ediately p rio r to vocalization. This resulted in their being able to say only one or two w ords on one inhalation. T here was n o air built up for plosive sounds and no airflow fo r fricatives. These children could how ever say plosives as well as fricatives in isolation, but the plosives were w eak and the airflow in the fricatives w as short. T he less afflicted cases could say m ore w ords per in ­ halation. T hey tended how ever to say as m any words as possible on one inhalation. T his resulted in incorrect phrasing, the phrasing being dependent on the num ber of words they could cram into one exhalation. T he plosive and fricative sound endings o f w ords were omitted. Often the articulatory movem ents were m ade, b u t these were not accom panied by sound. Inhalation to o k a long time and was very shallow. T his resulted in the straining of voices and a tendency to use a higher pitch tow ards the end o f phrases. 2. AIM S OF THE PRO GRAM M E: 1. D eep inhalation w ith controlled exhalation while producing sound. 2. Fast inhalation w ith prolonged exhalation while producing sound. 3. Im p ro vem en t o f speech — w orking fro m sounds to syllables, and from m ono-syllabic w ords to m u lti­ syllabled words. 4. Im provem ent o f speech in sentences, by breaking sentences down in to sh o rter m ore acceptable phrases which were w ithin the capacity o f each child. 3. THERAPY: T h erap y com m enced by trying to increase the ph o n a- tion time. (a) T h e time limit we tried to achieve w as ten seconds which none o f the cases could do. T his was attained by gradually lengthening the period o f vocalization on exhalation. T he follow ing tasks were given in th e training process: (i) H um m ing. (ii) Sustained blowing. (iii) P rolongating vowel sounds until ten seconds was attained. (iv) Prolongating fricative sounds. (b) C onsonant and vowel com binations: C onsonant and vowels were com bined: fo r exam ple pa, ta, ka po, pie, pou etc. and again we tried to reach the ten seconds limit. N o initial carry over from th e basic training was present. W ork was done on this aspect and th e goal was reached in a m uch sh o rter period o f time. As the vital capacity o f the children increased, so the vocalization also showed im provem ent. (c) We now introduced the stage w here a quick, deep inhalation and a long controlled exhalation with sound, was dem anded. F o r exam ple a — / a — W e w orked until they reached the stage w here they could prolong the vowel fo r ten seconds, inhale fo r tw o seconds and again vocalize fo r ten seconds, fo r sixty seconds w ithout stopping. (d) T he next step was the introduction o f words. W ords were built on the previous successes. F o r example ma m at m atter m atters m aternal m aterial pa pack p ale p attern patterning packaging, etc. 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 3. ) Page 8 P H Y S I O T H E R A P Y SEPTEM BER, 1973 M ARE YOUR DAY A LITTLE EA SIER ! You physios are a hard-worked group, we know. In the day’s work, environment and c o m f o r t b e e o m e m o r e a n d m o r e important — and while there’s not much we can do to help fix the background in which you work, you’ll find a comfy, practical working rig in the new special- purpose uniform we’ve designed with you in mind. It’s a continental style dress, with Bermuda-type shorts to match. A side vent in the skirt and the generous cut, mean that you’ll work more easily, and feel comfortable right through the hard day. Your option o f short or long sleeves, in drip-dry, hard-wearing fabric . . . white or saxe blue. Sizes 3 2 to 42. Elegance and efficiency . . . what more could you ask ? 4 th F loor, P ritch ard H ouse, 8 3 P ritch ard Street, JOHANNESBURG. T elephone 2 3 - 4 4 0 .J. 8 7 M ario n Avenue, G lenashley, DURBAN. T elephone 8 3 - 7 2 2 6 .H H i “ Fully illustrated catalogues and price lists o f our full range are available free to you. Just drop us a postcard (P.O. Box 7 5 2 , Johannesburg) or telephone 2 3 - 4 4 0 5 any time, including nights, weekends and holidays. W e’re also happy to execute phone orders, o f course. c 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 3. ) *e p t e m b e r , 1973 P H Y S I O T H E R A P Y Page 9 (e) In v?e started w ith tw o w ord sentences. T he length t the s e n t e n c e s was increased by adding m ore words c o n t a i n i n g plosive and fricative sounds to the sen­ tences-^ cxarnpie M y cat. M y c a t walks. T his cat walks. T his kitten talks, etc. (f) children h ad to be ta u g h t to use m eaning­ ful nhrases w hich were suited to th eir new ly acquired hreathing p attern . T his was started off by th e re a d ­ in g of simple sentences. W e w orked tow ards more complex sentences, w ith m ore w ords per sentence. F or exam ple T h e cat / sits. T h e cat / sits / on th e m at. I I w ould like / everybody / to com e I and help us / as soon j as they can m anage / Phrasing was initially indicated by the therapist. Q The children th en h ad to build th eir ow n sentences. In this way w e w orked tow ards carry over into spontaneous speech. (g) ^ e-pjje children w ere seen im m ediately a fte r they had received their physiotherapy treatm ent. T h r o u g h o u t th e program m e the th erap ist strove not to draw the children’s attention directly to their breathing. T h is was attained by referring only to their speech and w here they h ad to rest, and w here to pause and not to breathing per s6. F o r exam ple A child w as never told to “ take a deep b reath an d say. . . b u t ra th e r to “rest after you have said. . . an d “ before you continue saying. . . 4. RESULTS O F T H E R A P Y : A t the end o f the six m onths trial period: Cases 1 and 3, were able to phrase th eir sentences in the correct w ay and carried this over in to sp o n ­ taneous speech. Cases 2, 6 and 8, reached the stage w here phrasing was done by th e therapist. Cases 4, 5, 7, w ere still at step 5, learning to pronounce simple sentences, containing plosives and fricative sounds, in the correct way. ^Therapy was in terru p ted fo r tw o m onths during the M e m b e r holidays. N o hom e-program m es w ere given. A fter this period all th e candidates w ere still on the same level o f achievem ent except case 7 w ho h ad re ­ gressed. A fter th erap y w as resum ed, the latter case reached his previous level o f achievem ent w ithin three weeks. Now, after two m onths in th e new year, cases 1 and 3 are seen only once a week fo r th e purpose of m a in ­ tenance. Cases 2, 6 and 8 are on a spontaneous level during therapy b u t no carry over has occurred in other situations, fo r exam ple, class, hostel, playground, etc. Case 4: is w orking on the phrasing o f com pound sen­ tences. Case 7: is w orking on sentences w hich have a high fre ­ quency o f plosive and fricatives. Case 5: T his child proved to be too young fo r this study. T h erap y had to be done on an indirect level and the n o rm al program m e (as m entioned earlier) could n o t be followed. H e does h o w ­ ever show m arked im provem ent in spontaneous speech as such. Conclusion: T ape recordings w ere m ade during the different stages of the project. I t w as how ever very difficult to d o this experim ent on a scientific basis, because of th e difficulty in getting control groups, as well as the lim itations of th e scientific data. It is thus ap p aren t th a t this w as just an experim ent. T he program m e asks fo r refinem ent and should be done m ore extensively. I t was how ever shipwn by this experi­ m ent th a t by im proving th e breathing patterns, m ore distinct speech can be attained. R eferences: B E C K E T T , R . L.: T h e R espirom eter as a D iagnostic and C linical T ool in the Speech C linic, J.S.H .D . M a y 1971, Vol. 36, N o . 2, p. 235-241. , K E A T S , S.: Cerebral Palsy. C harles C. T hom as, Spring­ field, Illinois, U .S.A. Book Review F R O M C O N C E P T IO N T O B IR T H . R o b erts R ugh & L an d ru m B. Shettles. G eorge A llen & U nw in L td. R13,10. T h e authors o f this b ook are, respectively, an experi­ m ental em bryologist/researcher and a gynaecologist. W hile th e book is aim ed at prospective parents p ri­ m arily, it is w ritten a t a high ‘lay-level’ an d profusely illustrated w ith num erous charts, diagram s, p h otographs and some superb colour plates o f th e foetus in utero. P a rt 1 covers very lucidly and in g reat detail, th e anatom y and physiology of ovulation, fertilization, im ­ plantation and the subsequent grow th and developm ent o f the em b ry o and foetus. T he supporting photographs are fascinating, though i t is p erh ap s d eb ateab le w hether a susceptible p reg n an t w om an really w ants to com e face to face w ith the features o f her 5-6 weeks old foetus! T h e stages of labour are described, an d th e a ctu a l delivery w ell p hotographed in sequence, w hich gives one th e feeling o f actually watching th e birth. A ny physio­ therapist conducting ante-natal classes should find these of value in illustrating h e r lectures. C aesarian section is only briefly d ealt w ith, b u t no o ther deviations from the straight forw ard delivery are offered. 'R outine care o f the neonate, including explanation o f the A gpar rating and assessm ent, is discussed. P a rt 2 deals w ith ante- and p o s t-n a ta l' care and re ­ habilitation including lactation an d the value of nu tri­ tion and balanced diets. Exercises and relax atio n are recom m ended from th e 3rd or 4th m onth thro u g h to ‘ delivery and some sim ple exam ples shown, though no guidance is given ab o u t classes in this field. In the post­ n atal section exercises are described and illustrated, stress being laid on the need to seek sanction o f th e d octor o r p h y s i o t h e r a p i s t in form ulating a w orking pro­ gram m e. Fam ily planning and m odern contraceptive m ethods are evaluated. Finally genetics, heredity,, the R .H . factor, dom inant and recessive characteristics etc., are discussed and ta b u ­ lated, and a full glossary ’and extensive bibliography ro u n d off a boo k which contains a m ine o f in form a­ tion on a host o f topics w hich seldom fe a tu re in one book. T o th e lay w om an seeking info rm atio n in greater depth th a n th a t usually offered, I w ould ra te it highly fo r dealing w ith th e subject .very m uch in th e round. T o the physiotherapist intending to specialise in obstetric w ork, I think it w ould be a very useful ‘re­ fresher course’ to get her subject in to perspective before fu rth e r detailed reading a t a deeper m edical level, w hile to the established arite-natal* teacher it will be m uch appreciated by her. pupils fo r the excellent illustrations, th e quality of w hich m ust be responsible fo r the price! N . V . R osem ary H a rte (Reviewer) 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 3. )