I. Principles of treatment
A detailed evaluation of speech disorders before treatment can identify the impaired functions, clarify the level of functional impairment, carefully analyze the relationship between these impaired functions, make a judgment on the prognosis based on the severity of dysarthria, the site, scope and nature of the impairment, and formulate a rehabilitation plan. The order and method of treatment should be decided according to the results of the organ and articulation assessment, starting with the training of motor function, followed by the training of articulation and expression. The order of articulation should follow the principle of easy to difficult.
Relaxation training
Patients with spastic dysarthria have tense throat muscles and high tension of limb muscles, and by relaxing the muscle tension of limbs, the throat muscles can be relaxed accordingly. The treatment requires a quiet and relaxed atmosphere. Through a series of exercises to achieve a relaxed state, take a relaxed position, close your eyes and concentrate on the relaxed parts.
1. Relaxation of the feet, legs and hips
① Toes down for 3 to 5 seconds, then relax and repeat several times.
②Rotate the ankle joint, one foot at a time, and then relax.
③Sit with feet flat on the floor, step down forcefully for 3 seconds, then relax, and repeat several times to let the patient feel the relaxation of the calf force.
④Straighten the knee joints of both legs for 3 seconds and then relax, the patient should feel the thigh force and relaxation.
⑤ Contraction and tension exercises for the quadriceps and gluteus maximus muscles, hands on both knees (take a sitting position), torso probed forward, in an imminent standing position for 3 seconds, sit down and relax, repeat several times. Encourage the patient to experience the tension and relaxation of these muscles.
(6) Remind the patient that he/she should feel some relaxation in the lower limbs and hips.
2. Abdominal, thoracic and back exercises
①Focus your attention on the abdomen, chest and back, and keep your feet, legs and hips relaxed.
②Tighten the abdomen so that the abdominal muscles continue to contract for 3 seconds, then relax, and repeat several times. Ask the patient to pay attention to the back muscles and chest muscles that are also tense when closing the abdomen, and experience the relaxation when relaxing.
③ Encourage the patient to breathe deeply and smoothly when the muscles are relaxed.
3.Relaxation of hands and upper limbs
1.Focus your attention on the upper limbs and hands, while feeling the relaxation of the feet, legs, hips, abdomen and chest and back.
2.Clench your fist for a few seconds and repeat several times.
3.Raise both upper limbs forward to shoulder level, hold for 3 seconds, then relax and repeat several times.
4.Do the above actions together, make a fist and hold it for 3 seconds while raising your upper limbs flat, then lower your arms and release your hands for several repetitions.
4. Relaxation of shoulders, neck and head
①Shoulders shrug upward, hold for 3 seconds, then relax and repeat several times.
②Head drops forward, then smoothly tilts backward and slowly turns the head from one side to the other; then slowly turns the head to the left movement and closes the eyes to prevent dizziness.
③To ensure smooth and slow head movement, the therapist may stand behind the patient and hold the patient’s head with his or her hand for the above movements.
④Turn the eyebrows upward, frown the forehead, relax, repeat several times and notice the difference between feeling tense and relaxed.
⑤Close lips tightly and hold for 3 seconds; relax and open mouth. Repeat several times.
(6) Move the jaw slowly and steadily, rotating it up and down, left and right; relax.
⑦Crinkle up the face as hard as possible, hold for 3 seconds, then relax and repeat several times.
III. Treatment of mild to moderate dysarthria
1.Breathing training
Breathing is the driving force of diction, and a certain pressure must be formed under the vocal folds to produce the ideal vocalization and diction. The sitting posture should be adjusted. If the patient can sit steadily, the trunk should be straight, the shoulders horizontal, and the head kept in a neutral position. If the patient’s expiration time is short and weak, he or she can adopt a recumbent position and be helped by the therapist. This training can also be combined with vocalization and articulation.
2.Training to improve the composition of the voice
1.Training of jaw, tongue and lips
When the mouth cannot be closed, the skin near the central part of the jaw and the temporomandibular joint can be patted by hand to promote the closure of the mouth and prevent the forward extension of the jaw. The jaw reflex can be used to help lift the jaw and gradually make the lips close; to train the lip spreading, closing, protrusion and retraction movements, so that the patient can improve the obstacle of distorted pronunciation or replacement into other sounds due to the mouth and lip movement disorder; to train the tongue forward extension, retraction, lifting and lateral movement, etc., which can be done actively in mild cases, and the tongue depressor and manipulation can be used to help complete the above movements in severe cases; to use ice Rubbing the face, lips and tongue can promote the closure of the lips and tongue movement, 1-2 minutes/time, 3-4 times/day.
2.Pronunciation training
① Pronunciation start training: When exhaling, open the mouth round and pronounce “h”, then pronounce “a”; do the same method to pronounce vowels like (“s”, “When the larynx is tense and hoarse, you can do local massage and relaxation action, or let the patient do yawning action, which can make the vocal folds open completely and stop the vocal folds inward; take a deep breath, cough while breathing, and then gradually change the cough into pronouncing vowels.
②Continuous pronunciation: let the patient pronounce vowels for as long as possible with one breath, and gradually transition from pronouncing a single vowel to pronouncing two or three vowels with one breath.
③Volume control: instruct the patient to pronounce the “m” sound continuously; the “m” sound and “a”, “I”, “u” and other vowels. The “m” sound is pronounced together with “a”, “I”, “u” and other vowels, gradually shortening the “m” sound and lengthening the vowel sound; read aloud the words, phrases and sentences with the vowel “m”; maintain a relaxed position and count 1-20 after a deep inhalation. Count 1 -20, as loud as possible.
Pitch control: expand the range of pitches, instruct the patient to sing scales; conduct “sliding” training by sliding the vowels from low to medium to high; high to medium to low, etc.
⑤ Nasal control: inhale deeply, puff out the cheeks, hold for a few seconds, then exhale; use wheat sticks of different diameters, put them in the mouth and blow; practice pronouncing bilabial sounds, postlingual sounds, such as “ba”, “da”, “ga”, etc. “ga”; practice pronouncing fricatives, such as “fa”, “sa”, etc.; practice alternating labial and nasal sounds, such as “ba “, “ma”, “mi”, “pai”, etc.
3.Slow down the speed of speech
Patients with mild to moderate dysarthria may show that most of the sounds can be pronounced, but they become distorted sounds or rhythmical disorders, which can use a metronome to control the speed, starting from slow and gradually becoming faster, patients can pronounce with the metronome to significantly increase the clarity of speech, the speed of the metronome is decided according to the specific situation of patients.
4.Tone discrimination training
The patient’s ability to distinguish the sound is very important for accurate pronunciation. To train the patient to distinguish the sound, the first thing is to be able to distinguish the wrong sound, which can be done orally or by playing a recording, or in the form of group training, the patient can say a paragraph and let other patients comment on it, and finally the therapist can correct it, which is very effective.
3.Training to overcome breath sounds
The method of “pushing and propping” can promote the closure of the vocal cords to avoid the production of breath sounds; or use a vowel or a double vowel combined with a consonant and another vowel to induce the production of words, phrases and sentences.
4.Rhyme training
Due to motor disorders, many patients’ speech lacks intonation and accent changes, so use electronic piano and other musical instruments to let patients train intonation and volume with the change of sound. You can also use “visual speech trainer” to train. For the training of rhythm, a metronome can be used to set different rhythm and speed, and the patient can correct the rhythm with the rhythm.
D. Treatment of severe dysarthria
Severe dysarthria is a patient who is unable to perform voluntary movement or has very poor voluntary movement. The patient can gradually complete the dysarthria autonomously through manual intervention.
1.Breathing
The training can be done in a supine position with both lower limbs flexed and the abdomen relaxed, breathing calmly with the therapist’s hand flat on the patient’s upper abdomen, applying pressure smoothly with the patient’s expiratory movements at the end of inspiration, prolonging the expiratory phase through the rising movement of the diaphragm and allowing the patient to combine it with articulation. Alternatively, a sitting position can be adopted and the patient is encouraged to relax while the therapist stands in front of the patient or in front of the patient’s side and places both hands on the lower part of the patient’s thorax, gently squeezing at the end of exhalation to make the exhalation prolonged, taking care not to exert too much force. The elderly and osteoporotic patients should not use this method.
2.Tongue training
Severe patients have severely restricted tongue movement and are unable to complete forward extension, retraction and upward lifting. The therapist can put on the finger cover or use the tongue depressor to assist the patient to do the following exercises.
① Extend the tongue outward as far as possible, then retract it, roll it upward and backward, repeat several times and then rest, gradually increase the number of movements.
②Extend the tongue outward and lift it upward as much as possible, repeat several times and then rest, gradually increase the number of exercises.
③Lift the tongue up to the hard palate.
④The tip of the tongue is extended to the corner of one side of the mouth to the other side of the corner of the mouth movement, available tongue depressor to assist and resist the movement of one side of the tongue or increase the speed of movement on both sides.
⑤ tongue tip along the upper and lower gingiva to do a circular “sweeping” action.
3.Lip training
The patient can be helped to do the lip spreading, retraction and protrusion movement and to do the training of blowing inhalation and bursting sound through manipulation intervention. Patients with mandibular palsy may have a drooping or deviated jaw so that the lips cannot be closed. The therapist can place the left hand under the jaw and the right hand on the patient’s head to help the jaw lift and pull down the movement to gradually make the lips close.
V. Training of non-verbal communication methods
For patients with severe dysarthria, the speech therapist may choose to design alternative methods of verbal communication (such as AAC) to train according to the specific situation of each patient and the actual needs of future communication. The most common and simple methods used in China are picture boards, word boards, and sentence boards. With the rapid development and wide application of electronic science and technology, many developed countries have developed a variety of small size and easy to carry and operate communication instruments, and computers with special software systems are gradually used for the communication of patients with dysarthria.