Page 2 P H Y S I O T H E R A P Y SEPTEMBER, 1973 “In the spastic, breathing often exists at a purely vegetative level, close to the limits of life, lacking cortical control and inhibition required to a d a p t to any higher function such as speech. T h ere is no econom y o f o u t­ going air and voicing, which m ay be initially strong, rapidly fades aw ay to a breathy whisper. Shallow clavi­ cular breathing is often associated w ith postural defects and reversed breathing m akes controlled expiration alm ost im possible.” “B reathing is not separated from voicing. T h e tw o are practised sim ultaneously, although no attention should be placed on breathing.” As all previous attem pts to teach our cerebral palsied children effective breathing were n o t satisfactory, this experim ent by m aking use of a respirator to assist us in teaching these children correct w ay o f breathing, was undertaken. It w as a com bined effort w ith th e speech- therapist, in that speech follow ed im m ediately after the physiotherapy treatm ent. N O R M A L B REA TH IN G PATTERN. 1. R h y th m ic breathing. M echanical respiration is dependent o n m ovem ent of tidal air in and ou t of the lungs; it is related to rhythm o f the chest and abdom en. Breathing in: 1 . diaphragm and chest elevator muscles contract 2 . vertical, transverse and antero-posterior diam eter of th o rax increase 3. intra-thoracic pressure decreases 4. expansion o f the lungs. Breathing out: 1 . relaxation o f in sp irato ry m uscles and during farced expiration, contractio n of th e abdom inal muscles 2 . decrease in size o f thorax 3. intra-thoracic pressure increases 4. decrease in size o f th e lungs. A BN O R M AL ASPECTS IN THE CEREBRAL PALSIED BREA TH IN G PATTER N . 1. A rrh yth m ic, spasmodic breathing, related to the pre- respiratory behaviour of a foetus, p rio r to th e de­ velopm ent o f the pneum otoxic centre. In spastics the cause is the lack o f inhibition and in athetoids diaphragm atic spasm plays a large ro le in som e of the speech problem s o f the cerebral child. 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. ) ggpTEMBER, 1973 P H Y S I O T H E R A P Y Page 3 , pressure changes takes place b o th to get air into ' and out o f th e lungs, e.g., to blow up a balloon o r to s p e a k , one m ust use a ir under pressure. 2. T h e exaggerated stretch reflexes and la ck o f recip­ rocal inhibition causes both prim e m overs and antagonistic muscles to go into spasm w hile the child is breathing. W hen th e child w ants to force air out of the lungs, both abdom inal and chest elevator m uscles m ay contract, resulting in an expanding ribcage and a t the sam e time, contracting abdom inals pushes up onto the diaphragm , and the child is u n ­ able to force air out. 3 Reciprocal m o vem en t of respiratory muscles during breathing establishes a g reater efficiency of in sp ira­ tion and expiration. 3. R eversed breathing is present where, when during inspiration, abdom inal muscles co ntract and chest elevators relax. T herefo re th e re is n o reciprocal m ovem ent and the child is un ab le to breath efficiently. 4. Vital capacity i.e. approxim ate volum e of the lungs as determined by m easuring the largest possible expira­ tion after th e largest possible inspiration. Vital capacity depends on: 1 . size of th oracic cavity 2. posture 3. state of lung tissue 4 . fitness of patient. 4. V ital capacity when less than norm al, m ight be due to: 1 . weakness of respiratory m usculature 2 . bad posture e.g. scoliosis 3. reduced size o f th e thorax 4 . dim inished use o f lung tissue. Discussion. Reasons fo r using a resp irato r are as follows: (a) A ir forced into the lungs w ith the respirator, brings ab o u t a stretch m ovem ent from inside the lungs to the ribcage and if done repetitively, should cause an inhibitory effect, resulting in a m ore norm alised tone. (b) In addition, when air is forced into the lungs, the ribcage will m ove sufficiently to stretch the a b d o ­ m inal m uscles during inspiration, and as a result get a m ore norm alised forceful contraction of the abdom inal muscles during forced expiration. This leads to m ore efficient expiration. T his is of vital im portance in order to: (i) get enough pressure from forceful contracting abdom inal muscles (ii) have as a result a forceful pressure of outgoing air (iii) throw the vocal folds in to vibration. (c) C ortical control and inhibition should follow after the child has felt, experienced and practised the n orm al pattern of breathing, th a t is after spasm has been reduced. (d) W hen cortical control and inhibition is obtained, speech should im prove. 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 4 P H Y S I O T H E R A P Y SE P T E M B E R , 1973 Aims of T reatm ent with R espirator. 1. T o reduce sp a sm of inter cos tal a n d d i a p h r a g m a t ic muscles. 2. T o e n a b l e the child to exp eri enc e rh y t h m i c b r e a t h ­ ing. 3. T o facilitate a n o rm al i se d b r e a t h in g pa tte rn. 4. T o teach cor tica l c o n tr o l a n d inhib it ion . 5. O v e r a l l a im t o i m p r o v e speech. 6. T o r e d u c e oc cu rr e n c e o f b r on c h iti s, a s t h m a or r e sp i r at or y disorders. SU BJEC TS: T A B L E 1 Case Age Sex Diag nos is 1 15 yrs Male A lh e to i d 16 yrs M al e A t h e to i d 14 yrs F e m al e A th e to i d 4 14 yrs Fem ale A t h e to i d 5 8 yrs Ma le T en s io n A th e to id 6 9 yrs Fem ale Spastic 7 15 yrs M a l e Spastic 8 10 yrs Fe m al e Spastic On initial a sse ss me nt of these c hi ld re n , it was observed that th eir b r e a t h in g p a tte rn cons isted of ap ic al b re ath - inp only. T h e y c o ul d not do co n tr o l l ed lat era l costal or d i a p h r a g m a t i c br eat hin g. T h e ir b re a th in g p a tte rn s were assessed by: (i) o bs e rv at io n w i t h o u t th em being a w a re of it (ii) m a n u a l assess men t of their ab ility for localised br eat hin g. P a tte rn s o b se rv e d were: (i) sh a llo w ap ical b re at h in g fii) re v er se d br e at h in g (iii) a r r h y t h m i c s p a sm od ic bre athing . T lte ir v ital cap a citie s were, a s listed be low in T A B L E 2 Case D ia gno sis Vital c ap aci ty at beg innin g Vital capa city at end 1 At h e to id 3.3 4.4 2 At h e to id 2,3 2.8 ■; At h e to id 1,5 2,1 4 At h e to i d 0,4 0,8 5 T en s io n At h e to i d 0,3 0.6 6 Spastic 1,0 1,6 7 Spastic 0,9 2.0 8 Spastic 0.9 1.3 F o r th es e m e a s u r e m e n t s a dry sp i r o m e t e r was used Because the child ren co uld no t close th eir lips sufficiently a n d for long en o u g h periods, these m e a s u r e m e n t s only gave an idea o f i m p r o v e m e n t a n d are by no m e a n s loo per cent statistically co rrect. T h e ir c o m m u n ic a tio n t h r o u g h speech was p o o r and difficult to un d er sta nd . A pparatus. W e used the Be nn ett T h e r a p e u t i c Cy l in d e r Mo u n te d Un i t to assist us in this o b se rv at io n. T h e m a c h i n e assists b r e a t h in g by inflating the lungs d u r i n g in sp ir at io n under safe co n tr o l l ed pressure. T h e child c an stop the inflow vo lu n ta r i ly by a fo rceful e xp ira tio n. B r e at h in g can be regula ted to suit each c h i l d ’s b r e a t h in g p a tt e rn and c ap aci ty . T h i s is possible be ca us e the m a c h i n e doe s not cycle a u to m a ti c a l ly . Me di cal a ir was used as the re sp i r at o r y gas a n d dis­ tilled H ; 0 a t I 3 5 ° F as the hu midifi er to m a i n t a i n a de ­ q u a t e hu midif ica tion by a d d in g H , 0 v a p o u r to the p > str e am . PL A T E 1: N ote the m outh piece strap p ed across the child’s m outh and the use of a nose clip. A m o u th piece s t r a p p e d a cro ss the c h ild ’s m o u t h and the use o f a no se clip, eli m in a te d the possibility of nasal br eat hin g. See plate I. A f t e r a while it was fo un d that the c h ild ren c ou ld c o n tr o l th eir b r e a t h in g t h r o u g h the m o u t h only, a n d the nose clip was n o long er necessary. T h e c hi ld re n o ve r the age of ten year s r e sp o nd ed very well to the use o f the m a c h i n e , while those u n d e r the age of ten years ne ed ed e n c o u r a g e m e n t to get th em used to it. A ft er a b o u t a m o n t h th ey all ad ju ste d to the use. a n d act ual ly en joyed the tr ea tm e n t. T echnique. T h e c h ild r en were placed in recip roca l inh ibi to ry p o st u r e s f o r ex am p le an e x te n so r p a tt e rn child was posi ­ tio ne d with knees flexed, hip s flexed, b a c k u p r ig h t with he ad in n e u tr a l po si tio n a n d a r m s folded. T h e re as on being th a t in the c er e b r al pals ied children, in s p ir at io n is as soc iated with e x te n so r spasticity, th us the child is un a b le to b r e at h e in efficiently. By using reflex inh ib it in g p os tu r e s the r e s p i r a t o r y m u s c u la t u r e is freed fr om spasticity a n d so sh o u l d w o r k with m o r e n o r m a l ­ ised tone. 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. ) Tn all the c h ild re n we sta rte d with a systemic pressure f i O e m / H . 0 or even less, 5 c m / H . , 0 f o r tw o m in ut e s °1 h D i g r e s s e d u p to 15 cm/HX> for five minutes. T h e a” nTial pres sur e f o r c hil dr en is 1 5 c m / H 20 . it t o o k a p p r o x im a t e ly one m o n t h to w o r k the p re ssu re up to 15 c m / H . O . Da ily t r e a tm e n ts w e r e given fo r six m A t the be gin ni ng of the t r ea tm e nt , fo r th e first m o n th , the p h y si o th er a pi st gave pressure t o assist late ral costal d i a p h r a g m a t ic b re a t h in g a t the same time a s the rhild was on the respi rat or . As the c h ild re n im p ro v e d , assistance was slowly re duced a nd finally sto pp ed when they were able to d o lat eral co stal a n d d i a p h r a g m a t ic b r e a t h i n g w i t h o u t assistance of the thera pis t. R e s u l t s . 1 In creased vital c apa cit y, see T a b l e 2 f o r details. 2 I m p ro ve d d i a g p h r a g m a t ic a n d lateral co stal b r e a t h ­ ing w it h ou t assistance of m ac hi ne or ph y sio th era pi st. 3. I m p ro ve d b r e a t h i n g pa tte rn. I m pr ov ed c o m m u n i c a t i o n t h r o u g h im p r o v e d speech. (See sp e e ch -t he ra pi st report.) 5, Re d uc ti on of a tta ck s of a s t h m a a nd bro nc hitis. 6, T w o spastic c hi ld ren claim they c an walk long er distances w i t h o u t getting tired. C o n c l u s i o n . Aft er a six weeks sch ool ho lid a y d u r i n g whi ch no t r e a t m e n t wa s given, there was n o r e d u c t io n in the vital capacities m e a s u re d , or in the c o n tr o l of b r e a t h in g achieved pr ev iou sly be fo re the holidays. The i m p r o v e m e n t in c o m m u n i c a t i o n gain ed , was also maintained. A lo ng these lines it c ou ld be as su m e d t h a t the c a r r y ­ over a f te r the sch o ol ho lid a y s indicates t h a t v o l u n ta r y control t au gh t by this m e t h o d sh ou ld b e o f a lasting nature. . . . “ Reflex c o n tr o l of b r e a t h in g m ak e s life possible; vol untary co rtical modif ic ati ons m a k e s sp ee ch feasible.” Summary. Eight c er e b ra l palsied c hil dr en, t hre e spastics, fou r athetoids a n d o n e tension a th e to id were tr ea te d with the aid of a Be nn ett R e s p i r a t o r to i m p r o v e b r e a t h in g p a t ­ terns a n d speech. This o b se rv at io n was c ar r ie d ou t a t th e W est R a n d School for C e r e b r a l Palsied Ch i ld re n over a pe rio d of >ix m o n th s in c o -o p e ra ti o n with a spe ech thera pis t. SEPTEMBER, 1973 P H Y S I O T H E R I ipsomming. 'n P r o e f n e m i n g is ge doe n om die b r u i k b a a r h e i d van respirators vas te stel in die be h a n d e li n g va n se reb ra al ver lamd e kin der s. A g t k in de rs is d aag li ks vir ses m a a n d e behandel. Die h o o f doe l was om hierdie k in de rs se a se mh ali ng s- patroo n en sp r a a k te v e rb et er . Die s p r a a k t e r a p e u t en fisioterapeut h e t in no ue k o n t a k m et m e k a a r gewerk. References: 1. R E N F R E W , C. a n d M U R P H Y , K .: “T h e c h ild w ho d o e s n o t ta lk .” L o n d o n , H e in e m a n n , 1964. 2. V A N R I P E R , C. a n d I R W I N , J. V.: “ V oice a n d a rtic u la tio n .” L o n d o n , P itm a n , 1958. 3. C R 1 C K M A Y , M . C.: “S p e ec h th e r a p y a n d B o b a th a p p ro a c h f o r C e re b ra l P alsy.” S p rin g fie ld , T h o m a s, 1966. 4. B E S T a n d T A Y L O R : “T h e L iv in g B o d y .” L o n d o n , C h a p m a n a n d H a ll L im ite d , 4 th E d itio n , 1952. 5. C A T H E R I N E , P A R K E R , A N T H O N Y : “T e x t B o o k o f A n a to m y a n d P h y s i o l o g y T h e C. V. M o s b y C o m p a n y , 7 th E d itio n , 1967. A a n d ie K u ra to rs. S .A . V e re n ig in g v ir F is lo te ra p ie , G r o e p -b e g ift ig in g s fo n d s, P o s b u s 1194, J o h a n n e sb u rg. N a a m . . . . A d r e s O u d e rd o m m et v o lg e n d e v e rja a rd ag . B e ro e p _ ....... W e rk g e w e r --------- . . . . ----------------------------- H o e v e e l kan u b e k o st ig om m a a n d e lik s by te d r a ? ----- DIE KOLONI ALE Jjfs MUTUAL A P Y Page 5 f W O M T R € N T j MY fll'MI'ISI£L€ J I t o g k o m s ? n GROEPVERSEKERING b ied u spesiale voordele teen ver- m inderde tariewe, met in b eg rip van w aardevolle onge* skiktheidsvoordele. U finansiele toekoms is m e e r v e rsek e r as u b y II EIE VERENIGING se annuiteitsfonds aansluit. Dit kos m inder as u d e u r m iddel van d ie 1)G ro e p , ’-wyse versek erin g uitneem. Vul die onderstaande koepon in e n pos dit vir volledige b esonderhede oor hoe u uit u S.A. VERPLEEGSTERSVER- ENIGING SE GROEPVERSEKERINGSKEMA voordeel kan tre k __alle korrespondensie sal streng vertroyhk b ehandel word. 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. )