Integration of physical activity produces maximal results in speech therapy

By Barbara A. Ellicott, EdD, CCC-SLP

As a novice speech-language pathologist some 30 years ago, I was aware of the benefit of large motor exercise as a concomitant part of the speech therapeutic process; but since my techniques seemed unorthodox, I kept them a secret. How the situation has changed since I've been a private practitioner! Being free to employ innovative techniques and seeing outstanding patient progress is immensely rewarding. If employed effectively with sincere enthusiasm, physical activity can be of immense benefit for patients, from pediatrics to geriatrics. I have witnessed its therapeutic effectiveness for articulation, voice, disfluency and language development, to name a few.

The reasons for the success of this approach are multifold. Physical activity helps to dissipate anxiety, nervous tension and self-consciousness. This enhances patients' receptiveness and muscle function; creates a venue of exaggerated association and visualization, which reinforces memory; promulgates motor memory; and increases focus. Additionally, it's fun for both patient and therapist. Motivation is enhanced if pleasure is associated with therapy.

The following scenarios illustrate these points. (All names of patients have been changed to preserve confidentiality.) These scenarios reflect the positive results in applying physical activity in the therapeutic process for patients with problems in the areas of articulation, voice, disfluency, language development, autism, attention deficit disorder (ADD), and stroke-related pathologies. They represent some of the positive therapeutic outcomes that may follow when a speech-language pathologist integrates physical activities and humor in the therapeutic process.

The first case, regarding articulation, involved "Jon," age 8, who reportedly had attended school speech therapy sessions for four years for treatment of an interdental lisp without noticeable improvement. After only several sessions of employing physical activity, I observed marked progress.

After finding out that he liked superheroes, I asked him to tell me what characteristics he envisioned a superhero having. "Power and strength," he responded, flexing his muscles. Then I asked him if his preferred superhero had a vehicle. "A cool muscle car" was his response. I inquired if the car had a wimpy motor or a powerful motor. He stated, of course, that it was powerful.

I then asked him to retract his tongue, close his teeth, and produce the sound "zzz." His first attempt resulted in lingual protrusion and minimal phonation. I stood him by a child-sized, freestanding punching bag and produced an "s" with sufficient airflow. Each time the airflow was unobstructive, he was permitted to "attack" the bag with three hard punches. Next, he was instructed how to "put his motor on"/phonate "zzz" while retracting his tongue, smiling, and occluding his teeth. While initial phonation was weak, his articulation was considerably clearer following successive attempts interspersed with punching.

"Zak" presented with difficulty in the production of the vowelized "er." His posture was poor. His abdomen was extended, and clavicular breathing was evident. An active child, he enjoyed hands-on, large motor activities. Since he loved airplanes, the activity I chose involved his making an airplane motor sound (errr).

His initial attempts produced "awww." After demonstrating diaphragmatic breathing, using the analogy of filling a basketball with air for inflating the abdomen during inhalation, I demonstrated how to tighten the abs on exhalation and producing "ahhh." Zak responded successfully. He was asked to smile his biggest smile while retracting his tongue and then produce the powerful "ahhh" while hitting a punching bag, following with a smile and a strong "errr." He did this, to his and his mom's surprise.

Energizing with large motor activity enables this child to gain an intrinsic kinesthetic awareness. Simply employing the visual and audiological cues without the strong physical involvement did not yield half the produced results.

Another patient I treated was a senior citizen who presented with weak phonation, clavicular breathing, and prevailing hoarseness, for which his ENT could find no physiological etiology. His gait was relatively stiff, and extreme tension was observed in his facial, pharyngeal and laryngeal areas.

Progressive relaxation therapeutic techniques were somewhat effective, but not nearly as much as were physical exercises, such as intoning while bouncing a large rubber ball, lifting medium-weight chairs, and hitting a punching bag. He achieved outstanding positive results. While reading specific selections, he was asked to recall and visualize the physical exercise he had been asked to perform.

My experiences as a first-degree brown belt in karate, an American Red Cross water safety instructor, a student of yoga, and a marathon runner are of great value when working with people who stutter, from age 7 to 47. After the diagnostic session, during which multiple therapeutic strategies are discussed, I introduce them to physical endeavors for the purpose of dismantling tension. Such exercises are approximately selected to best match an individual's approximate level of fitness, flexibility and endurance.

For example, a 7-year-old appreciated jogging in place with knees high, vigorously hitting a punching bag, and pretending to swim under water with maximal effort in breaststroking and freestyle arm pulls. This same child really enjoys some basic yoga postures, including forward bend, plank, upward dog and down dog.

Smoothly transferring from yoga postures to diaphragmatic breathing techniques proved to be extremely successful. The more effective breathing resulted in increased, supported and sustained air flow. This graduated into sustained air flow during phonation and conversation.

Modifications are employed for patients who appear to have lower fitness levels and endurance capacities. Arm extension and stretching are substituted for punching, marching in place is substituted for running, slow breaststroke or freestyle arm strokes replace vigorous ones, and simple bending and stretching replace genuine yoga moves.

Patients of all ages learn to relax, laugh and enjoy the therapeutic processes and its lasting results.

As many experienced speech-language pathologists know, large motor activity is a "natural," almost expected, part of the therapeutic process when working with preschoolers and kindergartners. Healthy children have lots of energy, and they become most enthusiastic when provided with ample opportunity to express themselves while dissipating that energy.

One of the fastest ways to lose a young child's interest is to force him or her to be overly structured by remaining formally seated at a large table directly across from a lethargic, drone-voiced therapist. Requiring a child to be seated for a relatively short period of time has its place, but only after large motor therapy, when the child is more likely to be receptive.

One way I catch and maintain the interest of even extremely shy and reticent children is by engaging them in a marching regime to music, preferably music that they, their parents and I make ourselves by singing and clashing child-sized cymbals, triangles, tambourines, drums (or pot and pans), clickers and hit sticks.

I frequently place child-sized chairs in a variety of patterns around the room. The leader (clinician, parent) takes the initiative to call "sit," "stand," "fall down" or "turn around" or to command the child to go faster, slower (in extremes), jump, stop and so forth. Even the child who participates minimally in the therapeutic session participates maximally in his or her own home. Obviously, this is an example of receptive language acquisition followed by expressive language acquisition.

Permitting a child to be the leader is tantamount to helping him or her gain a sense of personal control. If parents can structure play scenes so that children feel in control, I tell them, then they are more in control as well. Some insecure, often first-time parents are reluctant to buy into this concept until they observe a dynamic positive difference in their child's behavior in therapy sessions, in contrast with more negative responses at home.

One of my favorite activities with preschoolers is pretending to be their robot, puppet or doll (whichever they prefer), with the parents assisting in the demonstrative process. I spontaneously take on my assigned role by instantly responding to orders of "go" and "stop." When the child says "stop," I freeze in a statuesque form in whatever position I happen to be in. The child's delight, laughter, enthusiasm and improved language development seem to be directly proportional to the extent of my exaggerated responses.

My preschool patients with mild to moderate autism demonstrate responses to structured and exaggerated large motor activities involving repetition. I have found they are most responsive to structured, representational play.

In utilizing representational play in conjunction with activities associated with day and night, I take advantage of the light dimmers in my therapy room. To illustrate night, I dim the lights enough to display the "moon" and the "stars." We pretend to be asleep only to be "awakened" by "full sun" and the "tune of morning." Then we rise and shine, pretend to get dressed, eat breakfast, and so forth. Once again, parents are only too happy to assist their children in controlling the dimmer switch while I perform activities associated with the select time of day.

Having worked with patients with stroke in hospitals, nursing homes and private practice over the years, I've learned that often adults are just as enthusiastic and responsive as children during the therapeutic process when humor, together with exaggerated physical responses, are employed. I have learned that an all-too-gentle conservative approach yields untrue results in so far as the patient's capacities are concerned, and the consequences can be demeaning and frustrating to the patients.

To illustrate this point, I will refer to dysphasia diagnostics. All too frequently, it is presumed that an older senior citizen (ages 70-80) who has had a stroke is doomed, too fragile or too "demented" to regain his or her pre-stroke status. Such a prevailing attitude tends to give rise to self-fulfilling prophesy.

Working in a trauma-centered hospital for some time now has given me credence for my therapeutic approaches to the extent that I frequently am called upon for a second opinion, especially for patients diagnosed with dysphagia.

Just recently, I received an order to evaluate a 76-year-old patient in surgical recovery. An Auschwitz concentration camp survivor, she had been through "living hell." When I awakened her from a sound sleep, her voice was weak, and she had difficulty keeping her eyelids from closing. I loudly, but humorously, clapped and sang, "Good Morning to you! Good morning, Mrs. Smith!" to the delight of an on-looking staff that applauded my singing, Oh, What a Beautiful Morning. I continued singing and, to my delight, my patient joined in, clapping and humming the remainder of the tune as her eyes opened.

Initially, when I asked the patient to produce a cough, she only pronounced the weak, throat-clearing sound of "ah-ha." "Mrs. Smith," I laughed, "you sound like the little engine that could!" She laughed so hard that a strong genuine cough was produced! I asked her if she could duplicate that wonderful cough using her belly muscles. I demonstrated, and she followed suit. "Good, Mrs. Smith, you passed the first part of the test. Now you can have a taste of some food!" I said.

On another occasion I was called in to give a second professional opinion–to confirm dysphagia–at the request of a patient's family. This patient, an octogenarian, was supposed to be NPO. He had been transferred to the hospital from a nursing home and was reported to have been extremely difficult and uncooperative.

Anticipating a possible challenge, I entered the patient's room. He said, "Hello, my dear, how are you today?" I introduced myself and explained my position. I mentioned that I would have to ask him to do silly things with his mouth and tongue if that would be all right. He chuckled and conceded. He had mild paralysis on one side of his face and seemed to have difficulty with bilateral labial twisting until I said, "Give me a Cagney!"–James Cagney, that is. With an ear-to-ear grin, he spontaneously twisted his "good" side almost to his ear and uttered, "Sure, baby!" That icebreaker gave way to his voluntarily producing a great productive cough.

Barbara Ellicott, EdD, is a speech-language pathologist, learning consultant and school psychologist in New Jersey. She can be contacted at Comprehensive Therapeutic Services, 300 Madison Ave., Madison, NJ 07940.