Intensive speech and language therapy for older children with cerebral palsy: a systems approach (pilot study).
Introduction
Cerebral palsy (CP) is the term used to classify a group of persistent disorders that are acquired before or during birth, or in infancy, which affect children’s movement and posture. In addition to affecting children’s larger movements for sitting, head control, mobility and use of their hands, CP can also involve the movements for speech. Muscles of the lips, tongue, vocal cords and those controlling breathing can become stiff and difficult to move with the precision needed for speech, or move unexpectedly creating unexpected sounds or breaks in speech. This type of speech disorder is known as dysarthria. The disorder can range from mild, with slight slurring of speech, to profound, where an individual cannot produce any intelligible words. Children with moderate and severe dysarthria commonly have very shallow breathing which is insufficient to sustain speech, and/or they have a low pitched voice, nasal speech, and a reduced range of vowels and consonants that can be produced accurately. As a consequence of these difficulties in making themselves understood, children can experience barriers in education and social activities.
At the moment there is little evidence to show that speech and language therapy changes the speech of children who have dysarthria and cerebral palsy. Dysarthria therapy has been described in textbooks and has been shown to be effective with adults who have acquired brain injuries. Therapy works by attending to the co-ordination and control of movements in speech. To produce speech, sound is created by air from the lungs being pushed through the vibrating vocal cords (the voice box), into the mouth where the jaw, lips and tongue move quickly and precisely to close off different parts of the mouth and this is what creates the sounds we recognise as consonants and vowels (speech sounds). Without adequate air pressure it is difficult to sustain speech and to create clear distinctions between the different speech sounds. So, therapy concentrates first on practising how to control the breath to produce voice and support speech, and then moves on to adjusting tongue and lip movements only when sufficient well-controlled air is guaranteed.
Method
We conducted a pilot study to examine if this type of speech and language therapy can increase the intelligibility of children with dysarthria and cerebral palsy. The pilot study was to lay the ground for a full-scale clinical trial.
Sixteen children who had cerebral palsy took part in the study. They were aged 11-18 years, had severe speech impairments and were very difficult to understand. As part of the study each child received three sessions of individual speech and language therapy a week, for six weeks. The therapy concentrated on teaching children how to control and co-ordinate their breathing and speaking, so that they had enough air to speak across short phrases and to maintain the volume and clarity of their speech. We recorded their speech in single words and sentences six weeks before, one week before, one week after and six weeks after the therapy. Three people who worked with the individual children and three people who had no experience of talking with people who have speech difficulties, listened to each of the recordings. This enabled us to calculate the children’s intelligibility to familiar and unfamiliar adults.
Results
We found that the children’s intelligibility increased after the therapy. People who worked with the children were able to understand approximately 15% more of the children’s speech in single words and sentences after the therapy than they could before. After therapy people who had no experience of talking with children with speech difficulties could also understand about 15 % more when children spoke in single words and about 10% more when they spoke in sentences.
There was no difference in children’s intelligibility when we compared recordings taken at six weeks before and one week before therapy. This suggests that the increased intelligibility after therapy was due to the therapy, rather than natural progress.
There was no difference between recordings taken at one week and six weeks after therapy. This means that children continued to use the skills they developed in therapy and maintained their higher intelligibility.
The increases in intelligibility that the children developed during the therapy have made a real difference to them, both at school and at home. It is now easier for them to be understood when saying single, important words and when speaking in sentences. Some children are twice as intelligible as they were before therapy. They can also raise their voice to speak across the classroom. Some of the things that children, their parents and school staff have said are given below:
“I am most proud of the progress I have made with my speech.” (During an annual review meeting)
“I like my speech now.”
“We are hearing sounds we have never heard before, thank you so much.” (Parent)
“We were told that __________could not make any progress after the age of 12, they were wrong. We are delighted with how much has changed and how much clearer __________’s speech is now.” (Parents)
“I’ve noticed a big change in ________ since she’s been working with you, she sits better, she uses more words, I can understand her better.” (Teaching Assistant)
“I saw a huge difference in her speech, much less nasal and muffled, much clearer, especially straight after a therapy session. Now I won’t accept her old speech, I say “Come on, I know that you can speak much clearer than that.” (Teaching assistant)
“This has made a huge difference to their lives and as a bonus, my job is easier now!” (Class teacher)
Discussion
The study was the second in a series that we need to undertake before we can conduct a large trial to investigate if the therapy is generally effective for children with speech difficulties and cerebral palsy. We are now testing how children’s voices have changed, as a result of the therapy, using specialist software to look at the sound waves created during speech. We will also test the therapy with younger children, aged five to ten years, to see if they too may benefit. The study with younger children will take place October 2008- December 2009. After that study we will apply to test the therapy with a large group of children with cerebral palsy in order to investigate its general effectiveness.
This information is not meant to replace the advice of any physician or qualified health professional. The information provided by Cerebra is for information purposes only and is not a substitute for medical advice or treatment for any medical condition. You should promptly seek professional medical assistance if you have concerns regarding any health issue.