Speech Therapy for VPI Bzoch: Pros and Cons

Tx for VPI usually takes the form of surgery or a speech prosthesis (more than mild - inconsistent problems, mild/ borderline patients) Consistent hypernasal, relatively large gap (more than sq mm), or multiple gaps - not benefit from SLP by itself (may need surgical or prosthetic management). Direct and indirect muscle training may be possible alternatives in certain cases. Classification of VPI into adequate, inadequate, or borderline (inconsistent) is essential.

Achieving correct placement for articulation may affect VELOPHARYNGEAL FUNCTION. This is particularly the case with BORDERLINE OR INCONSISTENT cases. Overarticulation can decrease the perception of hypernasality. Encourage oral articulation. Correct articulatory placement. Hoch (1986) reported that patients with inconsistent VPI but otherwise normal speech had the best chance of changing VP closure with nasopharyngoscopic biofeedback (bring movement to consciousness of px or byproduct - sound waves). Inconsistent pts. due to neurological problems or arrhythmia may improve with therapy. Consistently inadequate patients are poor candidates for Tx since their structural/neurological problems are too severe to overcome with Tx.

Visual and acoustic feedback may be of assistance in changing the hypernasal resonance if the pts. mechanism is capable of achieving adequate VP closure. This type of Tx is most appropriate for borderline/inconsistent cases with some occurrence of confirmed VP closure. Lotz & Netsell (1987) incorporated nose-plugs (cotton balls) to establish oral pressure. exaggeration of speech movements, increased mouth opening, increased loudness, projection of voice, and a bite-block (exaggerate articulation/ increase oral airflow) to establish accurate sound production.

Tx techniques fall into indirect vs. direct categories. >Indirect Tx's do not involve formal palate stimulation/ touching of VP structures, but are designed to influence VP closure (ex. Oral opening) and/ or balance of oral/ nasal resonance. *Articulation treatment - changes in oral articulation performance will influence positively VP closure for speech. Reduced amount of resonance/ airflow going to the nasal cavity since efficient articulation and directed airflow (sounds better). >Direct methods consist of sensory stimulation and/or cognitive focus on the palate while the pt. is engaged in some type of speech (mostly) or nonspeech activity. A. Speech appliance treatment - (rationale) long-term stimulation of the lateral and/or posterior pharyngeal walls may result in improved VP closure for speech B. Palatal stimulation treatment - (rationale) muscle strength and/or range of motion may be increased through stimulation of the soft palatopharyngeal walls or through therapeutic EXERCISE UNDER RESISTANCE (CPAP therapy - provide airflow and pressure through the nose/ or both). -Palatal stimulation treatment and speech production practice - Palatal stimulation treatment and non-speech production (should be temporary and translate to speech context) practice *VP port behaves different from speech and non-speech production. C. Biofeedback treatment - (rationale) improve performance through the use of a physiologic signal that is generally not available to a learner (nasendoscopy, nasometer - below the line, 24->22 nasalance score)

>The findings from two articulation studies were equivocal - INDIVIDUALS WITH CLOSURE DEFICITS WERE FOUND TO IMPROVE ARTICULATION SKILLS, BUT THIS IMPROVEMENT DID NOT RESULT IN IMPROVED CLOSURE FOR SPEECH IN ONE It is concluded that indirect Tx may be of some value in improving VP closure for speech, but additional management of the deficit will probably be necessary (with surgery/ prosthesis). Consequently, indirect treatment of VP closure for speech via articulation for more than mild cases, does not appear to be a viable alternative.

Speech appliances may show promise in the improvement of VP closure. Variables associated with success are age, gender, cooperation, and anatomy (i.e. adequate velar length and pharyngeal wall movement). p521 - Electrical and tactile stimulation methods may not be effective, however resistance methods (CPAP - continuous positive airway pressure) show promise in improving strength, range of motion, and provision of direct stimulation.

*Nonspeech activities are generally ineffective. (IMPORTANT FOR EXAM) A subset of individuals may benefit from biofeedback techniques (some subjects can utilize the sensory information and positively change VP closure).

Most persons who exhibit closure deficits for speech require surgical or prosthetic management (primary form of treatments). SLP's should refrain from using various palatal treatment methods unless they have specific clients who have demonstrated potential for change, and they have the capabilities to carry out such procedures empirically (numerical feedback). Trial period of therapy.

1. To change VP muscles by increasing their strength, endurance, or mass. 2. To change control of velopharyngeal activity by improving muscle coordination, rate of velar movement, or consistency of VP closure. 3. To change respiratory, laryngeal, or oral articulatory behaviors to reduce speech nasalization without necessarily improving VP function.

Phase 1 (40s to 60s): Speech Tx Works - Activities such as blowing, sucking, swallowing, etc. were conducted with the expectation that improved VP function in nonspeech activity would carry over to speech. In addition, articulation Tx and simple feedback re: nasal airflow was also felt to improve VP closure. p531 - Increased oral opening was also felt to result in reductions in perceived hypernasality. If oral impedance (oral cavity blockage) was reduced relative to nasal impedance, nasal airflow would decrease, and speech would be perceived as less nasal even though VP closure movements remained unchanged. Closed oral cavity (learned or physical nature) - accentuate NASAL resonance.

Speech Tx may not improve VP closure, but may reduced perceived nasalization. Moll (1965) observed that VP closure was not necessarily complete in normals during nonspeech activities. In addition, velar movements during nonspeech activities differed from those during speech. Many began to question the validity of using nonspeech activities as the basis for improving VP closure movements for speech. Interest was maintained in methods intended to stimulate velopharyngeal movement. The most commonly studied method was the use of the temporary speech prosthesis. Several authors reported increased pharyngeal wall movement. Cole (1979) noted that some believed that increased muscle activity resulted from resistance of the obturators to the movement of the palatal and pharyngeal muscles, whereas others felt that the presence of the obturator somehow served to stimulate the musculature.

p534 - Warren (1975) indicated that increasing the size of the oral opening resulted in less nasal airflow even if the size of the VP orifice remained unchanged. p534 - An acoustic model described by Lindblom and Sundberg (1971) was compatible with the notion that speakers who are least hypernasal for vowels tended to use the greatest oral openings. Clinicians and researchers noted that speakers with good oral articulation skills tended to be perceived less nasal than those with poor articulation and therefore suggested that improving oral articulation skills alone may lead to reduced hypernasality.

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Treatments consisting of speech activities are more likely to be effective VERSUS nonspeech. Currently. the most advocated Tx component is provision of instrumental feedback related to VP function or movement. Because awareness of velopharyngeal position and kinesthesis appears to be poor, use of instrumental feedback may be a logical treatment approach. Using feedback alone would appear to be useful only if the patient reaches VP closure in at least some contexts prior to treatment or quickly acquires the ability to reach closure in some contexts in the early stages of treatment. Obturator reduction to develop VP motion and incorporation into speech, as well as resistance techniques (CPAP) may also hold promise.

Individuals with inconsistent; borderline function; those with mild to moderate VP dysfunction; individuals who have recently received secondary palatal surgery; individuals with phoneme-specific nasal emission of air individuals who achieve VP closure

Noninvasive Tx's are needed for those with inconsistent/mild deficits, those who are *post-secondary surgery but are still hypernasal, and those who have phoneme-specific nasal emission of air. These methods would also be useful for those whose *VP mechanism may be capable of supporting normal speech, and for those for whom *surgery would be risky and/or costly, and for those who have VPI due to faulty learning.

Barring prohibitive anatomic or physiologic constraints, it should be possible, using appropriate behavioral approaches, to strengthen muscles of VP closure; to increase range of velar and pharyngeal wall movement; to increase the force of VP closure; or perhaps to modify the timing or pattern of VP closure. Tx techniques that can change balance of oral to nasal resonance, and oral to nasal airflow.

By Hakel, Marshall, & McHenry (2009)

Inadequate tissue with good innervation Classically associated with cleft palate

Adequate tissue with poor innervation (flaccidity, injuries to head/neck area) Classically associated with dysarthrias

Velopharyngeal Incompetence - lifts & obturators usually divertie to air.

-Diminished respiratory support -Inadequate laryngeal function -Distortion of vowels and consonants despite adequate articulatory function -Reduced oral pressures for sound production

Hypernasality Nasal air emission Decreased intelligibility, primarily due to weak pressure consonants Short breath groups Loudness

A total of 33 intervention studies were obtained, analyzed for methodological rigor, and summarized in the table. Interventions were classified into 3 categories: Prosthetic (Palatal lifts, nasal/nasopharyngeal obturators, palatal desensitization) Surgical (Pharyngeal flap surgery, pharyngeal implants, teflon injections) Exercise (Palatal training devices, resistance exercises with Continuous Positive Airway Pressure (CPAP))

Palatal lift Long-standing history Nasal obturator More recent

Props up soft palate Provides mechanical impedance to air attempting to enter the nasal cavity Compared with palatal obturator for velopharyngeal insufficiency. LIft - most commeonly used for VP insufficient

From Evidence based Practice Guidelines for Dysarthria: Management of velopharyngeal function Academy of Neurogenic Communication Disorders and Sciences

Better - flaccid (hyporeflexes - not much gag revlex) Poorer - spastic (hyperreflexes - a lot of hyperactive gag reflex) Tightness tends to make lift harder to retain Articulation Better - adequate or recovering Poorer - Poor Some modifications of lift can facilitate articulation, such as a dropped palate to decrease distance from tongue to alveolar ridge and palate. Incompetence - lift Inadequate - obturator

Better - yes Poorer - no Though desensitization procedures have been reported

Better - yes Poorer - no Presence of lift typically stimulates increased saliva production Presence of lift can make swallowing more difficult

Better - adequate Poorer - Poor Difficult to keep track of appliance Need external cues in place to monitor use Need to establish habits such as where to keep lift when not in use (such as when sleeping)

Better - stable or slow improvement Poorer - rapid improvement, degenerative

Use of palatal lift and palatal augmentation prostheses to improve dysarthria in patients with ALS: a case series

*The goal of this very early speech intervention is to reduce the likelihood of the establishment of abnormal compensatory articulation errors as a habit pattern before it occurs. *READ: Home programs must be individualized and include a number of key components (see middle of p. 47). Procedure for evaluating emergent language skills is no different for a cleft child than for other children. *However, early speech evaluation is particularly important because of the unique types of errors associated with cleft palate and the interrelationship between compensatory sound production and VP function.

First step: teach parents stages of normal language and speech development. Emphasis should be on the usual sequence of mastery. Second area: teach parents techniques for stimulating language development. Parents should be taught how to repeat and expand the child's utterances. *Parents should be taught to engage in child-centered and child-directed communication *Elicit desired verbal responses by repeating the child's vocalizations, by modeling play behavior with role playing, and other similar strategies *IGNORE the incorrect articulation and REINFORCE and MODEL the correct productions *Provide target sounds and words based on child's level of language and phonetic development.

Initial target words before palate repair should be vocalic and nasal-loaded with emphasis on words that do not begin with vowels (avoid glottal stopping). Suggestions: play with aspiration (/h/ sound); mouth opening and closing during /h/ production to stimulate /p/ production; alternate light nares occlusion; focus on pressure consonants and ignore hypernasality; encourage labial sounds using vowel + /w/ sequences *After palatal surgery, let child recover, When ready, words should be plosive-loaded, with anterior plosives used first (see Table 4-3, p. 52). An important area of parent education is in auditory training to recognize the difference between oral and compensatory articulations. Auditory discriminations -> Eliciting correct oral consonants production and extinguishing glottal stops using behavior modification techniques. Behavior modification uses three types of contingency responses - (1) positive reinforcement, (2) negative reinforcement, and (3) punishment

which acts as reward, increases the likelihood that a behavior will be repeated.

application of an adverse response to a behavior - it is intended to decrease the likelihood of a behavior being repeated. The parent should be trained to continue engaging in the task with the child, but not respond to the incorrect vocalization (see Table 4-4, p. 53).

behavior is ignored, the likelihood that it will be repeated is diminished - when a child in the early stages of speech development of babbling and reduplicated syllables produces a compensatory speech sound, the production should be ignored.

we want the child to understand that the parent recognizes his/her wish to communicate, but the parent must stress the accuracy of production (i.e., stress oral, non-glottal productions). Ignore the u-i ("cookie") (This is intelligible in context but not accurate) and reward the "cookie" (intelligible and accurate). *Looking for oral consonant (plosive, fricative, affricate) productions -> when patient produced an oral sound (e.g. plosive) then increased in accuracy (smaller steps of approximation). Easier to provide positive reinforcement since consistent achievement of goal. Parent education programs should be provided to all parents of babies with cleft palate because it may enable them to prevent the development of glottal speech.

EIP's are useful for those children who have demonstrated language delay; those not producing oral sounds; those at high risk for language delay/compensatory articulations because of a syndromic diagnosis; those who are developing a pattern of glottal stopping, etc.

EIP's are not necessary for those cleft palate children who are developing normal speech without intervention.

Focus of early sound play should be the production of open sounds, nasal sounds, and front sounds. Lip smacking, raspberries, etc. should be encouraged since they use the front of the tongue and lips. Sound play should be done with the nares open and closed as early as the baby will tolerate it, even before palate repair. It is important to occlude the nares for very short intervals and only after the child has inhaled.

Attempts at "pa-pa-pa" may produce glottal stopping - if so, change the production to "ma-ma-ma". When the baby repeats this production with the nares closed, a "p" sequence will be produced. If a child does not make speech responses after many attempts, revert to nonspeech lip and tongue sounds, such as raspberries, lip smacking, and loud "sighs" in order to engage the child in sound production.

First Word Attempts - the production of a variety of consonants and words can be enhanced by recognizing and reinforcing all the baby's oral sound attempts, even when they are nasalized, as is inevitable before palatal repair. Using principles of behavior modification and operant conditioning, any glottal stops should be ignored. When a baby babbles a glottal stop (vowel only) sequence, the adult should tack on a consonant /b/ and repeat the utterance. If the child attempts to repeat but still produces glottal stops, the nasal consonant /m/ should be added and repeated. This type of modeling and shaping provides reinforcement for the babbling itself but provides a model for more appropriate articulation play. If the child continues with glottal stopping, repeat the "ma-ma-ma" sequence with nares closed - the child will begin to hear and feel the production of the oral plosive.