(A) relaxation training
1, foot, leg and hip relaxation
a. Toe flexion downward for 3-5s, then relax, repeat several times, and
b. Ankle rotation, one foot at a time, and then relax.
c. Sitting position, feet flat on the floor, step down hard for 3s, then relax, repeat several times to feel the gastrocnemius muscle force and relaxation.
d. Straighten the knee joints of both legs for 3s, then relax, and the patient should feel the thighs exert and relax.
e. Contraction and tension exercises for the quadriceps and gluteus maximus muscles, hands on both knees (take a sitting position), trunk probed forward, in the position of about to stand up for 3s, then sit down and relax, repeat several times. Encourage the patient to experience the tension and release of these muscles.
f. Remind the patient that he or she should now feel some relaxation in the lower extremities and hips.
2. Relaxation of abdomen, chest and back
a. Focus on the abdomen, chest and back, but keep the feet, legs and hips relaxed.
b. Tighten the abdomen so that the abdominal muscles continue to contract for 3s, then relax, and repeat several times. Ask the patient to pay attention to the back muscles and chest muscles also tense when closing the abdomen, and experience the relaxation when relaxing.
c. Encourage the patient to breathe deeply and smoothly while the muscles are relaxing.
3.Relaxation of hands and upper limbs
a.Focus your attention on the upper limbs and hands while continuing to feel the relaxation in the feet, legs, hips, abdomen and chest and back.
b, clench your fist, then continue to relax for a few seconds throat, repeat several times.
c. Raise both upper limbs forward to shoulder level, hold for 3s, then lower them and repeat several times.
d. Combine the above actions to sit, make a fist and hold it for 3s while holding the upper extremities flat, then lower the arms and release both hands for several repetitions.
e. Remind the patient to pay attention to the contrast between the feeling of tension and relaxation. If the hands still feel tense you can shake the wrists smoothly until they relax.
3. Relaxation of hands and upper limbs
a.Shrug both shoulders upward, hold for 3s, then relax for several times.
b.Head drops forward, then smoothly tilts backward and slowly turns the head from one side to the other. Then slowly do the head turning movement, you can close your eyes to prevent vertigo.
c. To ensure smooth and slow head movements, the therapist can stand behind the patient and hold the patient’s head with his or her hands for the above movements.
d. Raise the eyebrows upward, wrinkle the forehead, then relax, repeat several times and note the difference between feeling tense and relaxed. e. Close the lips tightly, hold for 3s, then relax and open the mouth, repeat several times.
f. Move the jaw slowly and smoothly, rotate it up and down, then relax.
g. Crinkle up the face as hard as possible, hold for 3s, then relax and repeat several times.
(B) Breathing training
A. Breathing training
1. Place one hand on the diaphragm and the other hand on the 11th and 12th ribs on one side. If the patient is paraplegic, the therapist can stand behind the patient and place one hand on the patient’s diaphragm and the other hand on the 11 and 12 ribs on one side, or place both hands on the 11 and 12 ribs on both sides. Inhale smoothly through the nose and then exhale slowly through the mouth. Note the outward movement of the diaphragm and the upward and outward movement of the ribs. Correct the shoulder movements. Have a pause between each breath to prevent hyperventilation.
2. When the therapist counts 1, 2 and 3, the patient inhales, then counts 1, 2 and 3 to hold the breath, and then counts 1, 2 and 3 for the patient to exhale. When exhaling, pronounce “s”, “f” and other fricative sounds for as long as possible, but do not make any sound, after weeks of practice, pronounce 10s when exhaling and maintain this level.
3, continue the above practice, in the exhalation of friction sounds from weak to strong, or from strong to weak, strengthen and weaken the intensity of friction sounds. Make as many intensity changes as possible within one breath. Instruct the patient to feel the movement and pressure of the diaphragm, which indicates that the patient is able to control the exhaled airflow.
4. Exhale one long and one short or one long and two short, or one long and three short rhythmic fricative sounds in one breath, but without making a sound, such as s——. Exhale for as long as possible to pronounce a vowel, then two or three vowels in one breath, and then the fricative sound together with the vowel.
5.Count 1, 2, 3 in one breath in a low voice, and gradually increase to 1 to 10.
6.Change the intensity of pronunciation when counting, same as exercise 5
B. Upper arm exercise do upper limb lifting or rowing action to increase lung capacity. Exhale when the arms are raised to assist the breathing action.
C. Increase airflow with a transparent glass marked with a scale (cm), fill it with one-third of water, put a straw into the water, blow into the straw, observe the scale reached by the bubble and the duration of the bubble blowing, tell the patient the result of the bubble blowing, and record the progress.
(C) Pronunciation training
A. Pronunciation initiation
1. When exhaling, open the mouth round and pronounce the “h” sound, then pronounce the “a” sound audibly. After repeated practice, gradually reduce the time to pronounce “h” sound, increase the time to pronounce “a” sound, and finally practice pronouncing other sounds.
2, the same as the above exercise, do the fricative oral form, then do the vowel oral form, such as “s……a, s……u”.
3, hoarseness is caused by laryngeal tension, you can use friction and relaxation techniques. Massage and vibration massage can be performed on both chin hyoid muscle and mandibular hyoid muscle. After the massage, the laryngeal tension is reduced and articulation exercises can be performed. Another method is to have the patient yawn accompanied by exhalation and pronounce words in the exhalation phase of yawning. Because yawning can completely open the vocal folds and stop the inward retraction of the vocal cords.
4. Delayed dysarthria may have varying degrees of paralysis of the internal laryngeal retractors, and any of the following push-up exercises can be performed.
a. Make a fist with both hands and raise it to chest level, then push down suddenly with both arms to expel the gas.
b.Raise both hands to chest level and then suddenly push the chest wall inward with both palms to expel gas.
c.Suddenly press the armrests of the table or chair with both hands.
d. Raise both arms to shoulder level, bend the elbows, cross the fingers of both hands, and then suddenly force the hands apart.
In all cases, the patient should expel the airflow loudly, and then continue to practice pronouncing vowels.
5. A further way to promote articulation initiation is to take a deep breath in, cough on the exhale, and then change this articulatory action to pronouncing vowels. Once articulation is established, the patient should be encouraged to sigh loudly to promote articulation.
6. Explosive sounds can also be used to assist articulation initiation, such as: ba, bu.
B. Sustained pronunciation
1. When the patient is able to start the pronunciation correctly, then continuous pronunciation training can be performed. Pronounce vowel sounds for as long as possible in one breath, use a stopwatch to record the sustained pronunciation time, preferably up to 15-20s.
2.From one breath to pronounce the unit sound, gradually transition to pronounce two or three vowels.
C. Volume control
1.Guide the patient to pronounce the “m” sound continuously.
2, “m” sound and vowel “a”, “i”, “u” and so on together, gradually shorten “m” and lengthen the vowel sound.
3. If the patient continues to pronounce the bilabial “m” sound with difficulty, pronounce the nasal “n” sound.
4. Read aloud the words, phrases and statements with the vowel “m”. The purpose is to improve the exhalation and volume, to contrast the vowel sounds through the change of mouth and lip position, and to promote the resonance of vowel sounds.
5.Recite the sequence number 1 to 20, recite the Sunday, you can change your breath once, the volume is as loud as possible, keep a relaxed body position and inhale deeply.
6, in order to improve volume control, volume change training, can count 1 ~ 5, 6 ~ 10, the volume from small to large, then from large to small, or volume a large and small alternately. Vowels, the volume from small to large, from large to small, alternating between large and small volume. During the repetition exercise, encourage the application of maximum volume as the therapist gradually lengthens the distance from the patient until it is the longest distance the treatment room can accommodate. Encourage the patient to let the sound fill the room and remind the patient to relax and breathe as deeply as possible.
D. Pitch control
1. Expand the range of pitches and instruct the patient to sing scales. Any vowel or consonant vowel can be sung in succession, such as “a, a, a” and “ma, ma, ma”. If the patient cannot sing a complete scale (octave), focus on training three different pitches, and then gradually expand the pitch range later.
2. When the patient’s pitch is established, “slip” training can be carried out, which is a prerequisite for intonation training.
Pronounce the vowels from low-middle-high; high-middle-low; middle-high; middle-low; high-middle-high; and low-high-middle sliding.
3. The patient imitates the therapist by doing the following exercises.
la-la hello!
mama/mama
ma Have you eaten?
mamama/ma do you want a pen?
4. While listening, the patient imitates these different pitch changes and it should be clear that these pitch changes indicate different meanings or tones of voice. If the patient has mastered the above exercises, he/she can repeat some exclamatory sentences, question sentences and greetings.
E. Nasal voice control
1.Inhale deeply, puff out the cheeks, maintain for several seconds, and then exhale.
2.Use wheat sticks of different diameters, put them in the mouth and blow on them to help the lips close and increase the muscle strength of the lips.
3.Practice pronouncing bilabial sounds, back of tongue sounds, etc., such as: “ba, da, ga”.
4.Practice pronouncing fricatives, such as: “fa, sa”.
5.Practice alternating lip and nasal consonants, such as “ba, ma, mi, pai”, and soft palate training, please refer to the training of articulatory organs.
(D) Mouth surface and articulatory organ motor training
A. Ontogenic sensory neuromuscular stimulation method
1, sensory stimulation with a piece of ice from the corner of the mouth upward along the zygomaticus muscle belly upward, and can stimulate the laughing muscle, from the bottom to the corner of the mouth, time 3 ~ 5s, repeated stimulation, its effect immediately, but the duration is short. The mechanism is to stimulate the temperature receptors, the impulse reaches the central nerve through the fibers, the sensitivity of the muscle shuttle increases, the neuromuscular excitation, and the muscle contraction.
Another method is to use a soft bristle brush to brush gently and quickly along the above mentioned area for one minute. After brushing, the effect is re-stimulation after 20-30min appear.
2, pressure, pulling and resistance facial muscle activity is based on the coordinated movement of each muscle group. Re-exercise should be performed bilaterally and simultaneously.
a, pressure is implemented by the finger or thumb tip, such as the external implementation of tactile pressure on the sub-chin tongue muscle and pressure on the hyoid bone, which helps swallowing.
b. Pulling refers to the repeated tapping of the contracted muscle fibers with the fingers during re-exercise to stimulate greater contraction. For example, light tapping along the contracted smile muscle can facilitate smiling movements.
c. Resistance refers to applying a force in the opposite direction to the movement to enhance it. It can only be performed if the patient is able to do some degree of muscle contraction. The resistance force is applied to the key side, and only when the affected side is strong enough.
When a patient is not yet able to perform a movement without assistance, pressure and pulling techniques can be used to facilitate the execution of the movement. Pressure and pulling techniques are usually implemented first, and then resistance techniques are implemented as function improves.
B. Training of articulatory organs
1.Jaw raising
a. Open the mouth as wide as possible to lower the jaw and then close it again. Repeat slowly for 5 times and rest. Later increase the speed, but need to maintain the maximum range of motion of the upper and lower jaw.
b. Extend the lower jaw forward and slowly move from one side to the other. Repeat 5 times and rest.
2.Lip closure and lip angle abduction
a. Pucker the lips as far forward as possible (pronouncing u position), then close them backward as far as possible (pronouncing i position). Repeat 5 times and rest. Gradually increase the speed of alternating movements to maintain the maximum range of motion.
b. Tuck in one side of the mouth, maintain the movement for 3s, and then rest. Repeat 5 times and rest. Key and alternate movements on the affected side.
c.Close both lips tightly and clamp the tongue depressor to increase the force of lip closure. The therapist may pull the tongue depressor outward, and the patient closes the lips to prevent the tongue depressor from being pulled out.
d. Puff the cheeks for a few seconds, then suddenly exhaust the air, which helps to make a burst sound, and the patient can also squeeze both cheeks with his fingers while puffing.
3.Tongue extension, tongue elevation, alternating movement and circular movement
a. Extend the tongue outward as far as possible, then retract it and roll it upward and backward, repeat 5 times, rest and gradually increase the number of movements. a. The therapist can place the tongue depressor in front of the patient’s lips and have the patient stretch the tongue to touch the tongue depressor. b. Resist tongue extension with the tongue depressor to strengthen the tongue extension. c. Maintain the maximum range of movement and increase the number of repetitions to increase the speed of movement. A stopwatch can be used to record the number of repetitions and the speed of movement.
B. Extend the tongue out and lift it up as far as possible. Repeat the movement 5 times and rest. Gradually increase the number of exercises. You can hold your jaw with your hand to prevent the jaw from lifting up during the exercise. When the strength of tongue movement is increased, the tongue depressor can be used to assist and resist the upward lifting movement of the tongue tip to increase the strength of movement.
c. The tongue is elevated to the hard palate. The tip of the tongue may be placed close to the lower teeth and the tongue raised, repeated 5 times with rest. Gradually increase the number of movements.
d.The tip of the tongue is extended and moved from one corner of the mouth to the other. a Use the tongue depressor to assist and resist movement on one side of the tongue. b Gradually increase the speed of movement while doing the above exercise.
e. Do circular “sweeping” movements of the tongue along the upper and lower gums.
4.Soft palate elevation
a. Sigh hard to promote soft palate elevation.
b. Repeat the “a” sound and have a 3-5s rest after each pronunciation.
c. Repeat the blast sound and the open vowel “pa, da”; repeat the fricative sound and the closed vowel “si, shu”; repeat the nasal sound and the vowel “mni”.
d. Direct stimulation of the soft palate with a fine brush or other object.
e. If the soft palate is lightly paralyzed, rub the soft palate quickly with an ice cube and rest after a few seconds to increase muscle tone.
f, Pronounce the vowel immediately after stimulation while imagining the soft palate elevated, then alternate nasal and labial sounds as a control.
g. When pronouncing vowels, place a mirror, finger or tissue under the nostrils to observe whether there is air leakage.
5.Alternative movement
a.The alternate movement of the jaw does the mouth opening action.
b.The alternate movement of the lips requires the lips to pout in front and then retract.
c.The alternate movement of the tongue includes A tongue extending and retracting; B tongue tip raising and lowering in the mouth; C tongue moving from one corner of the mouth to the other side.
d. Repeat the movement as soon as possible, followed by pronunciation.