Hot Topic Blog - Oral/Pharyngeal Sensory-Motor, Orofacial Myofunctional, & Airway Information

A CASE STUDY - EFFECT OF ORAL SENSORY-MOTOR TREATMENT ON EXPRESSIVE LANGUAGE: PART 3

METHOD

The present case study focused on the principles of traditional Neuro Developmental Therapy (NDT) for cerebral palsy and flaccidity in addition to oral placement therapy (OPT). These involved thermal stimulation, icing, brushing, and stroking. Various NDT methods like Bobath’s and Rood’s approaches are bottom-up techniques involving both afferent and efferent stimulation (Bobath, B., 1971; Bobath, K., 1971; Rood, 1954; Krigger, 2006). Additionally, they involve sensory awareness and processing to assist in making motor responses voluntary, consistent, and spontaneous.

NDT is a very sophisticated form of whole body treatment which some may consider non-speech oral-motor exercise (NSOME). However, it is not NSOME. There is support for the use of non-speech work for those with neuromuscular impairments such as Alternating Hemiplegia of Childhood (AHC). Clark (2005) said NSOMEs have been used in the treatment of people with neuromuscular impairments to address overall weakness, endurance, alterations in muscle tone, and altered sensation. Ruscello (2008) also stated (p. 386), "It should be noted that childhood speech disorders caused by neuromuscular deficits... need to be treated accordingly" implying that NSOMEs may have value for these clients.

Both of the approaches used in this case study (oral sensory-motor treatment involving OPT and NDT) are based on the bottom-up techniques of treatment and afferent/efferent stimulation. A combination of these two approaches was used with a client diagnosed with Mixed Receptive and Expressive Language Disorder and Developmental Delay subsequent to AHC. The outcomes post oral sensory-motor/OPT/NDT sessions and the impact on language levels are discussed.

A three-year-old client (at the time of therapy) with AHC (diagnosed at 9-months at National Institute of Mental Health and Neurosciences - NIMHANS) was the participant in the study. The client exhibited frequent hemiplegic attacks lasting for 15-20 minutes. There were also quadriplegic episodes. The electroencephalogram (EEG) findings did not reveal epilepsy which was a key to the eclectic diagnosis of AHC. However, the client was advised to use anti-epileptic drugs by a process of elimination when a flunarizine dose did not reduce the frequency of episodes. As suggested in the literature, eight hours of sleep helped him recover him from a hemiplegic state.

Milestones

The client had delayed motor and speech milestones. He attained head-neck control by nine months of age, he skipped crawling, and he could sit with support by 15 months. He was walking with support at the time he was brought for speech assessment. Generalized hypotonia and ataxia were present.

His speech milestones were delayed. The client had babbling restricted to vowels and occasional use of his first word “amma” at one year, three months of age. Vowels used were /a/ and long “i” predominantly. Other vowels with lip rounding or spreading were not present in his babbling.

His oral structures appeared normal, but functions were reduced. He exhibited drooling, inadequate vegetative skills like sucking, biting, chewing, swallowing, and blowing. He was on a semisolid diet. He also exhibited inadequate lip seal, flaccidity in his oral musculature, and limited lingual movements.

His hearing and visual sensitivity were within normal limits. However, he exhibited nystagmus at the onset of hemiplegic episodes.

The client was not enrolled in any school due to his language delay. After one month of therapy (described below), the client was admitted into an inclusive play school. The coherence in the client’s language development and its reflection at school was obtained via a report from the teacher who stated the client demonstrated steady, monthly progress in oral expression (i.e., he moved from naming pictures, to expressing his needs in phrases, to saying and singing rhymes and lyrics, to oral picture description, to speaking in intelligible sentences and progressing in academics).   

Treatment

The client had a speech and language assessment at two years of age at Sriram Speech and Hearing Clinic. Earlier he had undergone traditional language therapy with few NSOME techniques for eight months at a private clinic. Due to limited changes in expressive speech, his parents sought speech therapy services at Sriram Speech and Hearing Clinic. The client was diagnosed with Mixed Receptive and Expressive Language Disorder and Developmental Delay. His receptive language age was 12-14 months (scattered), and his expressive language age was 9-10 months at age two years. His parents were advised to bring the client for regular speech and language therapy which was scheduled for three sessions per week on alternate days. Additionally, they were asked to continue occupational therapy and physiotherapy.

The client’s comprehension had improved with language stimulation techniques during prior therapy, but little generalization of speech movements had occurred with NSOME. Therefore, OPT along with a few NDT techniques were employed in a systematic manner per the sensory and motor needs exhibited by the client.

Plan for oral placement therapy

The initial plan was to attain lip seal and control, along with the ability to produce the vowels /u, i, o, e/, the labial sounds /p, b, m/ and the labio-dental sound /v/. The client’s mother was taught to perform thermal stimulation on the child’s cheeks and lips along with the oral placement for the aforementioned sounds. The home plan was the same. Language goals weren’t begun until the first eight sessions of oral placement treatment were completed. After eight sessions of therapy, the client was able to produce /pa/, /ba/, /ma/, and /va/ with minimal support. Labial sounds were combined with five vowels in CV (consonant-vowel) and VC (vowel-consonant) combinations with oral support for the next eight sessions. Language goals were started along with this treatment.

After sixteen sessions, thermal stimulation, brushing, icing, and flavoring were applied to the tongue. Oral placement for the sounds /t/, “th,” /l/, /r/, /n/, “j,” /k/, and /g/ was initiated. The home plan was given to the mother, and demonstration of the techniques was provided. Similar CV and VC combinations with five vowels were facilitated. Language goals were continued using these sounds. Simultaneous lexical expansion was done with the client when he attained the ability to produce target sounds and sound combinations with support. The hierarchy in acquisition of lexical expansion was followed in language treatment (e.g., family members’ names, animal sounds, and functional words were facilitated when lip and lingual sounds were established).The fricatives /v/ and “th” were facilitated as the last portion of oral placement therapy in similar fashion to the labial and lingual sounds

The results and discussion will follow in Part 4 of this series in December.

References

Bobath, B. (1971). Motor development, its effect on general development and application to the treatment of cerebral palsy, Physiotherapy, 57(11), 526-542.

Bobath, K. (1971). The normal postural reflex mechanism and its deviation in children with cerebral palsy. Physiotherapy, 57(11), 515-525.

Clark, H.M. (2005). Clinical decision making and oral motor treatments. The ASHA Leader, 10(8), 8-9, 34-35.

Krigger, K.W. (2006). Cerebral palsy: An overview. American Family Physician, 73(1), 91-100.

Rood, M.S. (1954). Neurophysiological reactions as a basis for physical therapy. Physical Therapy Review, 34, 444-449.

Ruscello, D.M. (2008, July). Nonspeech oral motor treatment issues related to children with developmental speech sound disorders. Language, Speech, and Hearing Services in Schools, 39, 381-391.

About the Author

Krupa’s Mission: I am a very ambitious individual with multi-tasking capabilities, prepared to take up challenges in handling a variety of pathological conditions. I have a personality determined to work to bring positive changes in my clients by imparting a structured treatment approach. My positives include exceptional understanding of different speech and language disorders, effective client communication, and team playing to name a few. I understand the need for professional communication and emphasis on team work which is of paramount importance in the rehabilitation process. Having been equipped with my education and experience, I am looking for opportunities to make significant contribution that can bring about positive changes in my patients.

Krupa’s Career: I started my career in 2011 and worked at a few child developmental centers and special schools. However, I was determined to start my private practice where I am free to employ my way of looking at a disorder or a condition. I happened to work with the pediatric population, predominantly children with Autism Spectrum Disorder, Cerebral palsy, ADHD etc. I do on-call visits to hospitals for bedside evaluations of adults with neurogenic communication disorders, addressing feeding, oral sensory-motor issues, and communication.

I received my undergraduate and post-graduate education at Sri Ramachandra University, Porur, Chennai, India. I was awarded a gold medal for academic and clinical performance. I like to work with a variety of disorders; however, oral sensory-motor programs are my prime area of interest. You may contact me via email: krupa1288@gmail.com.

This is Part 3 of a case study. Part 4 will be posted in December 2017.