Assess the overall phonation behaviour during spontaneous speech and when reading a text: posture, phonological respiratory coordination, speech rate and volume of the voice.
1.- EVALUATION PHASE.-
– Review of the reports provided by the family and/or issued by referral hospitals or other treatment facilities.
– Collection of data on family history and personal interest, as well as a history of the current disease.
– Clinical interviews with family members and/or those responsible for the patient, if necessary.
– Evaluation, assessment and diagnosis of the presence or absence of impairments in swallowing:
– Examination of the orofacial functions (breathing, exhalation, cough and gag reflex).
– Examination of the pharyngolaryngeal structures (paresis and/or facial asymmetry, tongue deviation, lip sealing, soft palate, jaws, temporomandibular joint and muscle tone).
– Examination of the orofacial mobility (eyebrows, lips, tongue, cheeks, jaw and soft palate): strength, range, speed, precision, motor stability and tone.
– Examination of chewing and swallowing pattern: normal or atypical.
– Examination of the phases of swallowing: oral preparatory phase, oral transit phase, pharyngeal phase and esophageal phase (swallowing abnormalities, salivary stasis, inhalation, fractionated swallowing, long pauses, voice changes, frequent coughing, shortness of breath, etc.).
– Swallowing examination adapted for children with cerebral palsy (sucking, swallowing, biting and chewing).
– Method of clinical evaluation Volume-Viscosity (MCEVV) to detect possible shortcomings in the efficacy and safety of swallowing: food bolus of 3 viscosities (nectar, liquid and pudding) and 3 increasing volumes (5, 10 and 20 ml.).
– Monitoring of peripheral oxygen saturation (pulse oximeter).
– Diagnose the type of dysphagia (oropharyngeal/esophageal, mechanical/functional).
– Assess the type of nutrition depending on the severity of the dysphagia: oral feeding/enteral nutrition through a nasogastric tube or gastrostomy tube.
– Set the type of oral-feeding diet: basal, ease of chewing and crushing.
– Determine the consistency of the liquid depending on the amount of thickener: nectar, honey and pudding.
– Inform the nursing department of the diets of patients with dysphagia, after the assessment upon admission.
– Advise the auxiliary staff regarding eating patterns to follow with patients with impaired swallowing.
– Order ENT specialist referral for additional assessments, if necessary.
-Evaluation, assessment and diagnosis of the presence or absence of impairments in the voice:
– Examination of the vocal function: acoustic voice analysis using IT software (Multi-Speech) calculation of the speech ratio and s/z test.
– Assessment of the phonological respiratory parameters: computerized spirometry, respiratory rate, and calculation of the various phonological respiratory times (phonation, expiratory, apnea, exhalation and maximum emission).
– Assess the overall phonation behaviour during spontaneous speech and when reading a text: posture, phonological respiratory coordination, speech rate and volume of the voice.
– Request, if necessary, referral to ENT specialist for an anatomical and functional examination of the larynx.
-Evaluation, assessment and diagnosis of the presence or absence of impairments in speech:
– Overview of the orofacial and pharyngolaryngeal motor: facial symmetry, exhalation, respiratory rate, chewing, swallowing, salivary stasis, orofacial praxis, etc.
– Adapted examination of the orofacial and pharyngolaryngeal motor for the child with cerebral palsy.
– Phonological articulation examination by means of repeating words and phrases.
– Induced Phonological Register by means of the presentation of images.
– Examination of overall speech intelligibility.
-Evaluation, assessment and diagnosis of the presence or absence of impairments in language (oral and written) and communication:
– Assessment of language in children in preverbal stage: visual and auditory attention, imitation, order tracking, communicative intention, vocalizations, etc.
– Assessment of verbal expression: evaluation of the ability to repeat, evoking, naming by using visual ability, recite automatic series, describe, discuss and express communication spontaneously.
– Listening assessment: to evaluate the ability to identify images, follow simple and complex commands and understand complex ideational material.
– Reading assessment: to assess the ability to discriminate between letters and written words, recognize written words, understanding of oral spelling, drawing and word matching and reading of sentences and paragraphs.
– Writing assessment: to assess the mechanics of writing, transcription of series of letters and numbers, basic dictation, naming by using written ability, spelling, dictated sentences and narrative writing.
– Assessment of melodic intonation and rhythm playback.
– Assessment of the ability to perform simple and complex calculations.
– Assessment of visuoconstructive skills.
– Diagnose disorders of language (aphasia), establishing the type of aphasia depending on the type of language affected (motor, mixed motor, sensory, anomic, overall, etc.).
– Drafting of speech therapy evaluation reports in which the results, diagnosis and treatment plan are set out.
2.- TREATMENT PHASE.-
– Establish the general and specific objectives of the intervention.
– Rehabilitation from swallowing disorders:
– Myofunctional therapy: active and passive exercises to improve mobility, tone, power and muscle strength of the affected organs (lips, tongue, jaw muscle, soft palate and temporomandibular joint).
– Electrical stimulation of facial and pharyngolaryngeal muscles.
– Beginning of oral food intake in patients that use enteral feeding tubes (nasogastric or gastrostomy).
– Countervailing techniques and swallowing manoeuvres appropriate to the type of disorder.
– Changes in the consistency of the diet, in bolus volume and viscosity of liquids.
– Monitoring of progressive patients diets in patients with dysphagia: fine purée, consistent purée, foods with constant texture, foods with any texture and normal diet.
– Assistance and/or supervision during meals with patient with dysphagia.
– Coordinate with the nursing department regarding diets of patients with dysphagia and report any changes in same.
– Advice to families and caregivers of patients suffering from dysphagia that are outpatients.
– Rehabilitation from voice disorders:
– Respiratory treatment: establish the correct respiratory rate, expiratory air control, increase or decrease the volume of voice and establish correct respiratory phonological coordination.
– Rehabilitation of postural control.
– Improve the acoustic parameters of the voice: tone, timbre, intensity, melody, intonation, etc.
– Rehabilitation from speech disorders:
– Treatment of motor speech processes to correct the articulatory defect: respiratory phonological coordination, posture, tone and orofacial muscle strength, resonance, phonation, articulation and prosody.
– Rehabilitation of expressive and receptive language disorders:
– Treatment of verbal expression:
. Speech rhythm disorders: speech reduction/logorrheic jargon.
. Phonetic disorders: correction of the impairments and deformation of phonemes, treatment of orofacial praxis, reacquisition of affected phonemes and dysprosody reduction.
. Phonological disorders: correction of the transformations of words by substitution, omission or displacement of phonemes (paraphasias).
. Lexical disorders: updating the lexicon, correction of lack of correct words (anomie) and facilitate the search for words.
. Syntactic disorders: correct agrammatism (“telegraphic speech”) or paragrammatism (random alterations of the elements of a sentence).
– Treatment of oral comprehension:
. GnosticPsycholinguistic disorder: access to the meaning of words.
. Psycholinguistic disorder: access to the meaning of words.
. Acoustic-mnesic disorder: facilitate the retention of verbal information.
– Rehabilitation of written language:
– Treatment of perceptual processes: visual and auditory discrimination.
– Treatment of lexical processing: visual route and phonological route.
– Treatment of syntactic processing: sentence structure and punctuation.
– Treatment of semantic processing: understanding of information.
– Treatment of short-term memory and working memory.
– Preparation, training and generalization of Alternative Communication Systems (ACS) for patients with significant limitation or inability to communicate with the people around them.
– Handling and advice on technical aids for communication adapted to the specific constraints of the patient: computers and letter, word or picture boards.
– Speech therapy intervention in infantile cerebral palsy:
. Orofacial muscle relaxation.
. Postural facilitation.
. Treatment for eating and the control of the drooling.
. Treatment for speech articulation.
. Expressive and receptive language stimulation.
3.- DISCHARGE PHASE.-
– Speech therapy reports for outpatients discharged in order to report on the progress of the patient from the start of treatment to the moment of discharge, considering the choice of whether or not to continue the speech therapy treatment.
– Drafting and implementation of specific action plans to strengthen already-acquired achievements.
– Advice to families and caregivers of patients with dysphagia on specific feeding patterns.
– Advice to families and caregivers of patients with language and communication disorders to facilitate verbal interaction and the use of communicators.
3.2. Final phase:
– Speech therapy reports on the final discharge in which the progress of the patient from the start of the treatment is reflected, including their achievements, deficits that may still persist, the possibility of still benefiting from speech therapy, and guidance on home management in the case of dysphagia or language and communication disorders.