ELENA A. DYAKOVA
Department of Social-Humanitarian and Natural Science Disciplines,
Institute of Bsiness Economics, Moscow, Russia
President of International Institute of Speech Pathology, USA
Published in: «Jornal of Educaion & Science. Pedagogy. Psichology. Medicine.» Vol. 1 (11), 2014
As one method of treatment for a number of severe speech disorders, massage of speech muscles has been in use for some time. The theoretical underpinnings for its use were provided in the works of the following Russian speech-language pathologists: M. B. Yeydinova, O. V. Pravdina, K.A. Semenova, and S. A. Bortfeld in the 1970s. Nonetheless, the techniques of applying differentiated massage in various cases of speech pathology have only been developed fairly recently and have yet to be more widely incorporated into the practice of speech therapy . However, among specialists in the field, there is no doubt as to the practicality of using massage in speech therapy, especially when treating severe speech disorders such as dysarthria, apraxia, rhinolalia, and stuttering.
Nearly ten years have passed since the first book, Therapeutic Speech Massage, was written ( Dyakova E.A. 2003, 2005, 2012 by the Academy; 2013 by Xlibris in Engl.). During this period, Therapeutic Speech Massage gained wide popularity among practicing speech language pathologists in different countries. Since the first edition of this book, many training workshops on Therapeutic Speech Massage have been conducted. In the past decade, it has been gratifying to observe the interest speech therapists have had in mastering the practice of speech massage.
It is well known that many speech language pathologists (SLPs) working in medical and academic settings use the techniques of Therapeutic Speech Massage in their work and endeavor to obtain expertise in this area. Until recently, however, there has been no focused or systematic university curriculum which teaches the use of massage techniques to appropriately treat the specific causes and development of speech disorders. Presently, a class in Therapeutic Speech Massage is included in the speech therapist training program of many Russian universities and is also offered as a special seminar in the continuing education program using a carefully developed curriculum.
The purpose of this article is to describe the methods of Therapeutic Speech Massage and to offer suggestions for its use in the treatment of speech disorders. We have endeavored to systematize and more fully present therapeutic speech massage techniques in order to provide a physiological foundation for the desirability of using massage in the practice of speech therapy.
Therapeutic Speech Massage (TSM) is an active method of mechanical intervention that alters the condition of the muscles, nerves, blood vessels, and tissues of the entire speech apparatus. Therapeutic Speech Massage is a technique that normalizes all the components of speech: breath support, vocalization, resonance and articulation, as well as the emotional state of people suffering from speech disorders.
TSM is focused on the muscles of the peripheral speech apparatus. Muscles of the articulation apparatus (i.e., tongue, neck, lips, and the mimic muscles of the face), the muscles connected with the function of the vocal chords, and the muscles of the respiratory apparatus all combine to constitute a unified muscle system, which produces speech. TSM covers all the areas mentioned above even when muscle anomalies are diagnosed for a seemingly unconnected local area.
Therapeutic Speech Massage is part of a comprehensive intervention speech pathology program for the rehabilitation of children, adolescents,and adults with speech disorders. Massage is used in speech therapy practice with people who have been diagnosed with speech disorders such as dysarthria, apraxia, rhinolalia, dysphasia, voice disorders, and stuttering. TSM also can be used for prevention of speech disturbances among children in the prespeech period of life who have different kinds of movement disturbances. In general, TSM may be used in all cases in which there are anomalies of muscle tone.
Therapeutic Speech Massage can be performed at all stages of speech therapy intervention, but its use is especially crucial at the initial stage of treatment. Massage is often a necessary condition of effective speech therapy intervention. Many years of practical experience working with patients with different speech disorders has demonstrated that application of TSM will considerably reduce the time needed for speech therapy. This is particularly true when working with people with oral-motor disorders. The use of TSM, which leads to a gradual normalization of muscle tone, often results in the spontaneous improvement in production of previously distorted sounds. In situations when a patient has marked severe neurological symptoms, using TSM especially at the initial stage of therapy may offer a better chance for positive results. For purposes of prophylaxis of speech disturbances, massage is used at the earliest stages of treatment with young children having neurological symptoms, especially children suffering from cerebral palsy.
Massage can be integrated with traditional speech therapy techniques. In working to overcome articulation disorders, massage is performed along with different kinds of oral-motor exercises. TSM is also important to use with relaxation exercises in training the voice and vocal respiration and improving a patient’s emotional state, especially in cases of stuttering.
Therapeutic Speech Massage can be performed by speech-language pathologists, disability specialists, medical providers, and physical therapists who have mastered the techniques of TSM, i.e.,those who have undergone special training and know the anatomy and physiology of the muscles that support speech, as well as the pathogenesis of speech disorders. Elements of massage may also be performed by parents who have been instructed and trained by a speech language pathologist.
Physiological Effects of Massage.
Compared to other parts of the human body, the face is quite generously endowed with nerve endings as well as blood and lymphatic vessels. This is reflected in the condition of the facial muscles that help to convey the subtlest changes in a person’s emotional state. It is the facial expressions, first and foremost, that reflect people’s mood and the state of their health. The facial skin is especially sensitive to mechanical intervention. This is the reason for the subtle inverse relationship between the state of the facial muscles and nerves that results from massage and a person’s mood and feeling of well-being. Massage has a beneficial physiological effect on the body as it promotes a number of localized and general reactions involving all the tissues, organs, and systems. The surface of the skin represents an enormous sensitive field that is a peripheral part of the cutaneous analyzer. Thus, it is intimately connected to the central nervous system. Massage affects not only the structural layers of the skin and its vessels and glandular apparatus but also the condition of the central nervous system (CNS). Massage results in overall neural activity changes. Lost or impaired reflexes become more animated, and the functional state of the CNS as a whole is altered. Massage improves the skin’s secretory function. It activates lymphatic and blood circulation within the skin and thus improves its nourishment and elevates the metabolic processes. The skin capillaries are also affected by massage. The capillary system is a reflexogenic zone of the vascular system. This means that massage-induced changes in the capillaries lead to pronounced changes in the entire vascular system. Massage causes the apillaries to dilate and increases gas exchange between the blood and tissues (tissue oxygen therapy). Rhythmic massage movements ease the movement of blood through the arteries and accelerate the outflow of venous blood.
Massage has a reflex effect on the entire lymphatic system, improving the function of the lymphatic vessels. Massage also brings about substantial changes in the condition of the muscular system. First and foremost, muscle fibers become more elastic, and their contractions increase in strength and volume. Muscle capacity increases, and muscles recover more quickly following exertion. The differentiated application of various massage techniques makes it possible to decrease muscle tone when the muscles are spastic and increase it when the articulatory musculature exhibits flaccid paresis and helps in forming and executing coordinated active voluntary movements of the articulatory apparatus.
The foundations of TSM depend upon recognizing the interactions and relationships between the muscles of the speech apparatus (namely all of the muscles of the face, head, neck and shoulders) and the primary speech muscles that perform movement in every moment of speech . Physical therapists seldom limit their work to the specific muscles which have been traumatized. They usually begin their treatment on the periphery of the target area and slowly work through a series of connected muscles, thus preparing the traumatized tissue to be more receptive to direct massage. This step by step approach is the defining characteristic of TSM. There is a great deal of research which demonstrates why this approach works.
Numerous investigations have shown the elasticity of muscle filaments (A. V. Sirotkina, et.al.), volume, strength and contractive function (I.N. Asadchikh, N.A.Belaya et. al.), and capacity of the muscles for work (A.V.Verbov, J.M. Sarkizov-Ceraziny , et. al.), all increase under the influence of massage. In addition, observation and study of the dynamics of biopotentials on myograms have shown that there is a reduction of tone in spastic muscles and a corresponding increase of tone in flaccid muscles after massage (A.V. Sirotkina, A.E. Schterenhertz, N.A. Belaya , K.I. Zavadina, et.al.). All of this research indicates that treating the primary speech muscles as part of larger muscle groups increase the ability of these muscles to benefit from the standard therapies used by speech therapists throughout the world. It is this research which provides the theoretical basis for TSM.
There is a complex interdependence between the amount of force used in massage and the body’s response. Light, slow stroking movements reduce irritation in the affected tissues. This has a calming effect and brings about a pleasant sensation of warmth and well-being. Energetic, rapid movements excite the massaged tissues.
Thus, Therapeutic Speech Massage has an overall positive effect on the body as a whole, causing beneficial changes in the nervous and muscular systems that play a primary role in motor speech production.
Basic Goals of Therapeutic Speech Massage.
- Normalize the muscle tone of the whole body, mimic, articulatory, vocal, and breathing musculature.
- Reduce the occurrence of paresis and paralysis of the muscles of the speech apparatus.
- Reduce pathological symptoms in the muscles of the speech apparatus, such as synkinesis, hyperkinetic disorders, spasms, hypersalivation, sucking reflex and/or biting reflex, etc.
- Stimulate proprioceptive, kinesthetic sensations to facilitate organization of movement. That is important in the case of apraxia.
- Activate muscle groups of the peripheral speech apparatus that fail to contract sufficiently and increase oral-motor range of motion for articulation.
- Help the articulatory muscles to form coordinated voluntary movements, which produce speech.
- Normalize the emotional state of those with speech disorders.
Before beginning any therapeutic procedures, the speech language pathologist should identify the form and structure of the speech disorder and then raise the question of whether massage is appropriate. As a rule, the primary indicator for massage is change in muscle tone, which can be observed both in the general musculature and in the speech muscles. Even with a medical diagnosis, the speech language pathologist should perform an independent diagnostic examination of the condition of the speech muscles. This will aid the therapist in identifying a massage strategy for each individual case.
The speech language pathologist should determine the state of the following: muscles of the upper half of the chest; muscles of the neck; facial muscles; oral-motor muscles. Muscle condition is established through examination, palpation, and observation while the patient performs dynamic and static exercises.
Examination. When examining a patient/client, one should observe the position of her/his head relative to the chest and note any habitual asymmetric postures. In examining the face, one should look for possible asymmetry in the form of a leveling of the nasolabial fold, a drooping mouth corner, or a widened or narrowed palpebral fissure, as well as a chronically half-open mouth or drooling. Also the therapist should go on to examine the skin. Massage affects the skin first and foremost; therefore, the choice and especially the apportioning of massage techniques to some extent will depend on the skin condition.
Palpation. Palpation of the articulatory muscles allows the speech therapist to more precisely identify the type of muscle tone impairment. The use of palpatory diagnostic techniques requires that the speech language pathologist develop “tactile memory.” Tactile memory is the recollection of sensations that occur when palpating muscles and the integumentary system. These sensations are acquired only by practice through repeated palpation of the various parts of the neck, head, and face (lips, cheeks, tongue, etc.). In doing so, it is important to obtain a good sense of normal muscle tone and skin tension. The therapist must be aware of the condition of the patient’s muscle tone. Muscle tone can be high (hypertonic) or low (hypotonic). It is best to determine muscle tone with the patient in a supine position and with the muscles as relaxed as possible.
The speech language pathologist must first have an idea of normal muscle tone. Only by comparison with the norm can one determine articulatory muscle tone through palpation. Normal muscles are in a somewhat tensed state (optimal tone). A normal muscle has a soft, springy, elastic consistency and can be probed without pain. When muscle tone is increased, the muscles are denser and can be rigid, so it may be difficult to perform passive movements. With low muscle tone, the muscles are limp and flaccid to the touch.
Muscle palpation is performed in two stages. First, the surface layer of the muscle is probed using the fingertips with the fingers slightly bent. Then, without lifting the fingers, the speech language pathologist gradually penetrates deeper, examining the condition of the muscle’s middle and deep layers.
Increased muscle tone in the larynx is identified, as a rule, by placing one’s palm against the front of the neck. By doing this, one can feel the dense tense muscles, and the larynx does not move upward when swallowing.
Protuberances. Through examination and palpation, one also discoversa number of protuberances that are important in determining the direction of massage movements and the location of biologically active points. In the facial area, one can easily feel the frontal eminences and, under them, the supraorbital ridge and the upper and lower edges of the eye socket. To the front of the ear canal, one can feel the zygomatic process of the temporal bone and the entire length of the zygomatic bone. Behind the exterior ear canal is the mastoid process of the temporal bone. The zygomatic bone joins the paired maxilla, the body of which contains the sinus cavity. The mandible has right and left halves. There are two processes at the posterior edge of the mandible; the rearmost of them ends in an articular head, which is easily felt in front of the tragus when the mouth is opened and closed. A hollow can be felt in this area with the mouth in the closed position; this is the area of the temporomandibular joint. The ability of the mouth to open and close, as well as chew and articulate, depends upon the condition of this joint.
The condition of the movements (both general and articulatory) is assessed by performing the motor function tests used in traditional speech therapy methods. Assessments are made of the range, speed, dynamic, fatigue threshold, strength, and coordination of movements.
As a rule, muscle tone pathology in the articulatory muscles is accompanied by impairment of articulatory muscle mobility (paresis or paralysis), which is expressed in distorted pronunciation.
Impairment of the orbicularis oris muscle leads to distorted pronunciation of the sounds in cases where articulation involves the lips. These are, primarily, the bilabial consonants p, b, m, and w. The pronunciation of the labial vowels o and u may also be distorted as the articulation of these sounds requires active lip movements.
With paresis of the tongue muscles and the neck muscles, especially the suprahyoid muscle group (digastric, stylohyoid, mylohyoid, geniohyoid, and others), impairment occurs in the tongue’s mobility and ability to change configuration, protract and retract, and perform lateral movements. This leads to impaired pronunciation of most consonant sounds (especially the alveolar), which require the tip of the tongue to move actively.
When the styloglossus, geniohyoid, digastric, and other muscles that support the backward and upward movements of the tongue’s root are affected, one typically finds impaired articulation of the velar consonant sounds and a loss of clarity in the pronunciation of the middle and low vowels.
When the tongue muscles on one side are affected, there typically occurs a lateral pronunciation of a number of consonants. When the muscles of the soft palate are affected (the glossopalatine, palatopharyngeal, and other muscles), the voice becomes hypernasal.
Based on the results of a preliminary diagnostic examination, the speech-language pathologist should prepare a set of massage techniques outlining the sequence and methods for performing each type and a tentative treatment schedule (number/ frequency of massage sessions). Only after doing this should the SLP proceed with massage.
Types of Massage Used in Speech Therapy
The use of Therapeutic Speech Massage involves of several kinds of massage:
- Differential (activating and relaxation) massage based on the methods of classical massage techniques
- Acupressure massage (of biological active points), which can be used for both activating and relaxing of the muscles
- Massage using special devices such as speech-therapeutic probes, tongue depressors, a toothbrush, pointed tapping devices, and small finger-sized devices to stimulate the surface tissues, etc.
General Recommendations for Massage
Therapeutic speech massage is performed in a clean, comfortable, warm, and well-ventilated room. Generally, two to three sessions per week conducted on successive days or every other day may be sufficient. Massage is usually performed in cycles of ten to twenty sessions. These cycles may be repeated with intervals of two weeks to two months between them.
The duration of a single session may vary depending on the degree of impairment, the patient’s age, stage of therapy, and duration of the therapy sessions. Initial sessions typically last five to seven minutes and reach twenty to twenty-five minutes toward the conclusion of a course of treatment, depending on the age of the patient.
Before commencing a course of massage with a child, the speech therapist should explain to the parents why this form of treatment is necessary and effective. The patient should not experience pain during the massage. However, it should be kept in mind that massage of the tongue and muscles of the oral cavity can cause unpleasant sensations, especially in children. To help make a child comfortable, one can demonstrate a massage technique on another child who is already used to it or entertain the child with a brightly colored toy or interesting story. If the child is excessively agitated or displays a negative attitude toward the procedure, the first sessions should be very short and limited to stroking the tip of the tongue, lips, upper, and lower jaw. One should never begin a massage session with the most severely affected area; it should be approached cautiously and gradually.
Practice has shown that unpleasant sensations quickly fade away, and children gradually become accustomed to the massage procedure. In any case, the child should always feel an affectionate, friendly attitude toward them on the part of the speech therapist. This kind of attitude, as a rule, is the decisive factor in establishing contact with a child.
Body Position for Therapeutic Speech Massage
Before beginning the procedure, the patient should assume a resting position. Assuming the proper position will facilitate relaxation of the muscles, ease respiration, and also provide a comfortable position for the therapist while performing massage.
- The patient lies on the back, arms beside the body, with legs lying freely and toes slightly turned out. A small flat pillow is placed under the head, reaching the upper edge of the shoulder blades. The therapist stands/ sits behind the patient’s head.
- The patient’s position is similar to the first position described above. The therapist assumes a position to the patient’s right. The therapist’s left hand is placed near the crown of the patient’s head to keep it in position while the right hand performs the massage motions. This posture is used in massaging the tongue, lips, cheeks, and masticatory muscles through both their external and internal surfaces.
- The patient sits in a chair with a high headrest. The therapist assumes a position behind the patient’s head.
In speech therapy may be used several kinds of massage techniques:
- Stroking. This is an indispensable technique that is used to begin each session. Stroking is alternated with other techniques, and each massage session ends with it. The importance of this technique is that it increases blood circulation in the surface vessels, decreases muscle tone, and helps regulate the breathing. There are three varied stroking techniques that are practiced in Therapeutic Speech Massage. These are the following: superficial stroking and deep or embracing stroking.a. Superficial stroking. This is the mildest, most low-impact technique—a gentle form of effleurage. It is used to reduce the tone of the muscles of the facial and articulatory musculature. It is performed as follows: with a sort of caressing motion, the hand (palm) glides along the skin surface, lightly touching it. The hand-to-skin contact should be soft and gentle with the patient barely sensing the motion. It should not evoke any dermovascular reaction in the form of flushed skin. Superficial stroking must be performed slowly and rhythmically.b. Deep or embracing stroking. This is the most intensive stroking technique used to affect the receptors of the deeper muscles and vessels. It has a somewhat stimulating effect on the central nervous system. The technique is as follows: The palm lies snugly and evenly against the part of the face or neck to be massaged and glides along the surface, following all its anatomical contours exactly. At the same time, the stroking motion must be uninterrupted and slow.
- Rubbing. It can be performed with the pads of the index and middle fingers or the thumb alone, the heel of the hand, or the entire surface of the palm. The back surface of the fingers, bent into a fist, may also be used. Both straight and spiral movements may be used.
- Kneading. Like rubbing, this technique is performed on specific muscle groups. Kneading has the greatest muscle-activating effect of all techniques. It consists grasping, displacing, pulling up, compressing, squeezing, pinching, and rubbing the tissues. Kneading produces the greatest increase in muscle tone and strengthens muscle contractions. This technique is in fact a form of passive exercise for the muscles and is used when the muscles show functional deficiency and decreased tone. Kneading is performed with the pad of the thumb or the thumb and index finger together or the thumb and all the other fingers together. When squeezing and rubbing, the muscles are squeezed between the pads of the thumb and fingers. The rubbing motions of the fingers may go in various directions: lengthwise, laterally, or in a semicircular or spiral pattern. In the “tweezers” kneading technique, the tissues are grasped, pulled upward slightly, and passed through the fingers. For the pinching technique, the thumb and index finger grasp the tissues superficially and make a pinching motion.
- Vibration and tapping. Vibration alters interstitial exchange and improves tissue nourishment. Strong, hard vibration increases muscle tone while light, weak vibration decreases it. Tapping is used on the face, especially in areas where there are nerve outlets and also where there is little subcutaneous fat—for example, on the forehead, cheekbones, and mandible. The vibration technique is performed with one, two, or all the fingers, with a fluctuating motion of varying frequency and amplitude. Tapping is produced with the tips of the index and middle fingers, creating an intensive tapping motion. The movements are performed with one hand, with both hands working at once or with both hands working alternatively.
- Light pressure on the pressure points. This technique, improves blood and lymph circulation and the metabolic processes, is used in regions where there are exit points of fascicle nerve endings. These are the so-called acupressure points. As a rule, any stroking concludes with some pressure on these points.
In TSM practice, individual massage techniques are not usually applied in isolation; rather,combinations of techniques are generally employed. The choice of massage techniques depends on muscle tone condition and motor capabilities as well as pathological symptoms of the patient. When beginning a program of TSM, one must keep in mind that there is a complex interaction between the massage activity of the therapist and the feedback reaction from the patient. As a rule, light slow stroking lowers tissue excitability, relaxes the muscle, gives a pleasant feeling of warmth, and creates an emotional state of peace and comfort. This method may be recommended when muscle tone is heightened. Energetic, quick, active motions raise the sensitivity of tissues, increase muscle tone, and may be recommended when muscle tone is low. Therefore, the choice of massage motions and their methods of execution in TSM will be determined by the tonicity of the disturbed muscles. When the muscles of the peripheral speech apparatus are hypertonic, the use of relaxation massage is indicated. This would include the following methods of classical massage: stroking (superficial and deep), light vibration, and acupressure relaxation massage. For this, the following sequence of massage motions is recommended: the muscles of the neck, the muscles of the shoulders, the mimic muscles, the muscles of the lips, and the muscles of the tongue. In cases of hypotonicity of the muscles of the periphery speech apparatus, activating massage is used. This would include the following methods of classical massage: stroking in combination with rubbing, kneading, strong vibration, tapping, and activating acupressure massage. In cases of muscle hypotonicity, a different sequence of massage motions is recommended: the mimic muscles, the muscles of lips, the muscles of the tongue, the muscles of the neck and the shoulders. It is also important to note that the exact program of massage motions will depend upon the individual problems of the patient suffering from speech disorders.
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