The Effect of an Intensive Block of Bobath Therapy
on Speech Breathing in a Child with Cerebral Palsy
(a pilot study)
Lynzi Crisp MRCSLT
Marie Stanley MCSP
INTRODUCTION
Speech production is a specific act of breathing requiring a flexible, well-controlled and co-ordinated respiratory system to accommodate and adapt to ventilatory and mechanical demands1. Speech breathing requires a
dynamic interplay between relaxation pressure and muscular pressure to support lung volume and air pressure for speech production.
Children with cerebral palsy frequently present with speech breathing difficulties, due to their poor postural control, abnormal muscle tone and reduced ability to co-ordinate the timing and grading of the musculature of the
respiratory mechanism2, 3.
RATIONALE
To investigate whether an intensive block of Bobath therapy, addressing postural control and co-ordination of movement, impacts on speech breathing and intelligibilty
POSTURAL CONTROL/CO-ORDINATION OF MOVEMENT
Postural
Tone
ALTE
RE D
BIO
M
EC
H
CT
INFLUENCE
Handling
(includes structured use of the environment and play)
U
SPEECH
BREATHING
PARAMETRES
BREATHING
Air pressure
S
•
RU
GE
AN
CH
• Observation
of postural
tone &
patterns of
movement
Analysis
A
ST
CS
I
N
L
RA
ESSENCE OF THE
BOBATH CONCEPT IN
THERAPY
Flow
Postural
Alignment
Patterns of
movement
Loudness of
voice
Pattern
IMPACT
Intelligibility
Chest Wall Shape
Breath group
length
Volume of air
• Active Participation with Function
RESULTS
Breath
group length (volume)
RESULTS
MU
An increase
in length
the sustained
production of a vowel but no significant changes were noted in
Breath
group
(volume)
SCLE W KNESS
EA
the increase
connected
samples.
An
in speech
the sustained
production of a vowel but no significant changes were noted in
the connected speech samples.
Breath group
length (volume)
RESULTS
10
Sustained vowel
9
10
8
• Increased
expiratory
pressure
An
increase
in
the sustained production of a vowel
but no significant
changes were
noted in
9
RESULTS
the
connected
speech
samples.
indicated:An increase
in the sustained production of a vowel but no significant changes were noted in
7
8
• Increased
GROSS MOTOR FUNCTION CLASSIFICATION SYSTEM (GMFCS): Level III
• Reduced breath group length (number of syllables/ breath)
• Reduced speech intelligibility.
• Reduced intonation and loudness of voice
seconds
seconds
seconds
• Fluctuating postural tone
• Reduced confidence when conversing
with peers.
• Imprecise articulation
Expiratory
pressure
Water Bubble
Manometry
- 5cm²
Day of baseline measurement
10
Loudness
(pressure)
5
9 Loudness (pressure)
9
4.5
Changes
in expiratory pressure were noted in the results of water bubble manometry.
5
8
8
Changes
in expiratory pressure were noted in the results of water bubble manometry.
4
Loudness (pressure)
There
was
a(pressure)
slight decrease in voice loudness from 92 dBA pre- and 88dBA post-therapy.
4.5
7 Loudness
7
There was
a slight decrease in voice loudness from 92 dBA pre- and 88dBA post-therapy.
3.5
4
Changes
in
expiratory
pressurepressure
were noted
in thein results
of of
water
6
in expiratory
were noted
the results
waterbubble
bubble manometry.
manometry.
6 Changes
3
Pre-therapy
Pre-therapy
3.5
Pre-therapy
5 was
There was
slight
decrease
in voiceinloudness
from 92
pre-preandand
88dBA
post-therapy.
a slight decrease
voice loudness
fromdBA
92 dBA
88dBA
post-therapy.
5 aThere
2.5
Post-therapy
Water Bubble Manometry - 5cm²
3
Post-therapy
Post-therapy
4
Pre-therapy
Water Bubble Manometry - 5cm²
4
2
2.5
seconds
• Fatigue
3
Post-therapy
1.5
2 5
2
5
Water Bubble Manometry - 5cm²
1 4.5
1.5
Water
Bubble
Manometry - 5cm²
2
1
4.5
0.5
1 4
1
0
5
4
0
3.5
0.5
5
1
2
3
0
4.5
3.5
1
2
3
3
0
4.5
Pre-therapy
1 43
2
3
2.5
1 Day of baseline measurement
2
3
Pre-therapy
Day of baseline measurement
Post-therapy
3.5
4
2.5
2
Post-therapy
Day of baselineDay
measurement
3
2
of
baseline
measurement
3.5
1.5
Pre-therapy
2.5
1.5
Loudness
(pressure)
3
1
Post-therapy
Pre-therapy
2
1
0.5
Changes
pressure were noted in the results of water bubble manometry.
2.5 in expiratory
1.5
Post-therapy
0.5
Loudness (pressure) 0
There 2was a slight1 decrease in voice loudness from 92 dBA pre- and 88dBA post-therapy.
0
3
Changes in 1.5
expiratory0.5pressure 11were noted in 22the results of water
bubble manometry.
3
Dayfrom
of baseline
measurement
There was
a slight
decrease
in voice loudness
92 dBA
pre- and 88dBA post-therapy.
0
1
impact
speech
DayManometry
of baseline
measurement
- 5cm²
1 Water Bubble
2
3
• Confidence
• Aware of speech difficulties and difference in comparison to peers
Seconds
• Noisy nursery environment
• Increased contact with unfamiliar people
Seconds
Seconds
Seconds
3
Personal Factors:
in
Day of baseline measurement
10
• Asymmetry affecting alignment –
postural scoliosis, convex to the right
Environmental Factors:
in speech
Seconds
Seconds
Participation:
at the mouth
Post-therapy
Pre-therapy
Post-therapy
3
4 10
10
Sustained vowel
9
2
3 9
9
1
8
2 8
10
8
0
7
1 7
9
7
1
2
3
0 6
6
Pre-therapy
8
6
Pre-therapy
5
1
2
3
Pre-therapy
Day of baseline measurement
Post-therapy
5
7
5
4
Post-therapy
Post-therapy
RESULTS
6
4
4
Day
of
baseline
measurement
3
Pre-therapy
Breath group
length
(volume)
5
3
3RESULTS 2
Post-therapy
Loudness (pressure)
4
2
An increase
in the
production of a vowel but no significant changes were noted
1sustained
2Breath
group
length (volume)
Changes in(pressure)
expiratory
pressure were noted in the results of water bubble manometry.
3
Loudness
1
0
1
An increase
in the
sustained production of a vowel but no significant changes were noted in
the connected
speech
samples.
There
wasina20 slight
decrease
in voice
loudness
92 results
dBA pre88dBA
post-therapy.
Changes
expiratory
were
noted
in the
of
water
bubble
manometry.
1pressure
2 from
3 and
0the connected
1
2
3
1 speech samples.
There was a slight decrease in voice loudness from 92 dBA pre- and 88dBA post-therapy.
2 baseline measurement
3
vowel
DaySustained
of
01
Day of baseline
measurement
Sustained
vowel
1
Water Bubble2 Manometry - 5cm² 3
seconds
Activities:
10
Sustained vowel
Sustained vowel
6
4
the connected
speech samples.
5
seconds
Body Function and Structure:
the
connected
speech (volume)
samples.
Breath
group length
• No significant improvements
6
theof
connected
speech samples.
7 a sustained
duration
vowel
Pre-therapy
Sustained
An increase
in the sustained production
of vowel
a vowel
but no significant changes
were noted in
intelligibility
5
seconds
seconds
The results
Cerebral palsy - Choreoathetosis
• Decreased proximal stability due
to poorly sustained muscle activity,
particularly abdominal muscles.
Sustained vowel
RESULTS
MAIN OUTCOMES
lengthproduction
(volume) of a vowel but no significant changes were noted in
An increaseBreath
in thegroup
sustained
Breath group length (volume)
CLIENT: 4 year old • Involuntary movements – alternating
movements – wide ranging proximately
and smaller writhing distally
RESULTS
CONCLUSION
An intensive block of eight sessions of Bobath
Therapy focusing on improving postural stability
and alignment, reducing fluctuating tone and
involuntary movements, will show improvements in
the client’s speech breathing (loudness of voice and
syllables per breath length) and intelligibility.
• Loudness of an open vowel –
Sound Level Meter
• Maximum expiratory pressure
(cmH2O) – water bubble
manometry1
• Sustained phonation of an open
vowel – digital recording.
METHODOLOGY
•Design: Single-subject ABA design
•Intervention: Three week therapy block – 8
sessions, approximately 75 minutes long. Bobath
trained Speech and Language Therapist and
Physiotherapist.
• Breath group length from digital
recordings of short narratives and
the naming of familiar multisyllabic
words.
• Speech intelligibility from digital
recordings of short narratives and
the naming of familiar multisyllabic
words.
In order to
0.5
intelligibility, an intensive
block
0
Day of baseline measurement
5
of Bobath Therapy should be
4.5
1
2
Water Bubble Manometry
- 5cm²
4
augmented with a more direct
5
4.5
speech production, such
4
activities.
Pre-therapy
as,2.5
3.5
voice loudness and breath
Post-therapy
2
1.5
3
1
2.5
0.5
2
0
group length in speech
3
Day of baseline measurement
3.5
approach to specifically target
3
Seconds
MEASUREMENTS
Seconds
HYPOTHESIS
Pre-therapy
Post-therapy
1
1.5
1
2
3
Day of baseline measurement
0.5
0
ACKNOWLEDGEMENTS:
1
2
Thank you to our client and her family
in agreeing for us to share this work
3
Day of baseline measurement
and for all of the support from our
colleagues at The Bobath Centre and
other UK Bobath Centres.
INTERVENTION
• Weight bearing through limbs to reduce involuntary movements and promote improved trunk
activity.
Reference List
1. Hixon, T. J. & Hoit, J. D. (2005). Evaluation and management of speech breathing disorders: Principles and Methods. Tucson, AZ: Redington Brown.
• Improve proximal stability.
2. Hardy, J. C. (1964). Lung function of athetoid and spastic quadriplegic children. Developmental Medicine and Child Neurology. 6: 378-388.
• Improve grading of movement and ability to sustain midrange positions.
3. Solomon, N. P. & Charron, S. (1996). Speech breathing in able-bodied children and children with cerebral palsy: a review of the literature and implications for clinical
intervention. American Journal of Speech-Language Pathology. 7(2): 61-78.
The Bobath Centre for children with cerebral palsy
T: +44 (0)20 8444 3355 F: +44 (0)20 8444 3399 www.bobath.org.uk