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Treatment of velopharyngeal closure for speech: discussion and implications for management.

Abstract

The velopharyngeal closure mechanism acts as a valve to separate the oral and nasal cavities during speech and swallowing. Velopharyngeal closure deficits are generally identified by the speech-language pathologist and corrected through surgery or speech prosthetics. However, there is a small subset of clients who may benefit from treatments using task specific muscle rehabilitation procedures. This review article addresses the following topics: structure/function relationships of velopharyngeal closure, motor programming of velopharyngeal closure, aims and findings of various types of muscle treatment programs, discussion and rationale of successful muscle treatments, and guidelines for utilizing muscle treatment for the management of clients with velopharyngeal closure deficits.

Keywords: Velopharyngeal closure, muscle treatment, nasal emission, hypernasality.

Introduction

Velopharyngeal closure is the neurophysiologic act of partitioning the oral cavity from the nasal cavity during speech and nonspeech activities. Thompson and Hixon (1979) characterize the velopharyngeal closure mechanism as a valve whose actions act to separate the oral and nasal cavities. Moon and Kuehn (1996) describe the mechanism for speech as an articulator that must operate according to rules of neuromotor programming, and whose activity must be synchronized with the actions of other articulators to attain perceptually acceptable speech.

McWilliams, Morris, and Shelton (1984, 1990) indicate that velopharyngeal closure for speech consists of velar movement and contact with the lateral and posterior pharyngeal walls. The velum moves in an upward and backward direction to articulate with the pharyngeal walls. Normal speakers exhibit differential patterns of muscle activity of the velum, lateral pharyngeal walls and posterior pharyngeal wall (Iglesias, Kuehn, & Morris, 1980; Shprintzen, Lencione, McCall & Skolnick, 1974; Zwitman, Sonderman, & Ward, 1974). That is, they achieve closure but the articulators contribute in different ways depending on the speaker. Velopharyngeal closure for speech allows a speaker to generate sufficient air pressure and flow for the production of pressure consonants and also permits the production of voiced sounds without hypernasal resonance.

Speakers who are unable to achieve velopharyngeal closure or who exhibit faulty timing of closure often demonstrate problems with speech production and such problems manifest in articulation and resonance disorders (Kuehn, 1979; Morris, 1992; Warren, Dalston, & Mayo, 1993). Articulation problems are normally found with the plosive, fricative and affricate sound categories, since they require the generation of high intraoral air pressure (McWilliams et al., 1990; Peterson-Falzone, Hardin-Jones,& Karnell, 2001; Shelton, Hahn, & Morris, 1968; Shelton, Morris, & McWilliams, 1973). These pressure sounds, may be produced with nasal emission, or the client may use compensatory substitutions in place of the pressure sounds. Audible nasal emission is the auditory perception or air passing through the nose during the production of a pressure sound. The speaker may produce the sound at the correct point of articulation, but nasal emission accompanies the production. Compensatory errors are sounds that are used in place of pressure sounds and generally produced at a more posterior point of articulation than the intended sound. For instance, one of the most frequent compensatory errors utilized by speakers with cleft palate is the glottal stop. It is produced by bringing the vocal folds together to create a complete constriction and then releasing the built-up air pressure created by the lungs.

Resonance is the product of the transfer function of the laryngeal sound source (Peterson-Falzone et al., 2006). The vocal tract acts as a filter to selectively modify in different ways the complex laryngeal tone that is created by the vibration of the vocal folds. In normal speakers, English vowels and oral sonorants are produced primarily with oral resonance and little if any nasal resonance. If there is a velopharyngeal closure deficit, vowels and oral sonorants may be produced with excessive nasal resonance. The listener perceives hypernasality due to coupling of the oral and nasal cavities. Although hypernasality is the most frequent resonance problem, other resonance disorders such as hyponasality, mixed nasality, and cul-de-sac resonance may also be identified in the speech of speakers with velopharyngeal closure deficits.

Generally, the etiologies of such problems are structural or neurological, and surgery or prosthetic management are the primary means of treatment to achieve velopharyngeal closure for speech (McWilliams et al., 1990; Peterson-Falzone, Hardin-Jones,& Karnell, 2001; Shelton, Hahn, & Morris, 1968; Shelton, Morris, & McWilliams, 1973). That is, clients may present with a closure deficit that is caused by a structural problem such as cleft palate, or they may have a neurological problem that limits the muscular actions of the velopharyngeal muscles. In addition to surgical and prosthetic management of these clients, some clinicians have developed different behavioral treatments aimed at improving velopharyngeal closure for speech (Lotz & Netsell, 1987; Ruscello, 2004; Tomes, Kuehn, & Peterson-Falzone, 2004). The treatments are quite diverse and include: (1) treatment of compensatory articulation errors with the aim of indirectly improving closure by improving range of motion, speed, and/or skill development; (2) increasing muscle strength, speed and/or range of movement through therapeutic exercise programs utilizing speech or nonspeech stimuli; (3) the application of different sensory agents such as tactile or electrical stimulation to increase range of movement and/or skill development; and (4) improving range of movement and/or skill development by providing the client with biofeedback information of various types.

Practitioners who treat speakers with cleft palate, particularly on an infrequent basis need to be aware of all treatment options. While surgery and prosthetic management are the typical treatments, there is a small subset of clients who may improve velopharyngeal closure for speech through behavioral treatment. It is important that the practitioner be knowledgeable of such options, since one treatment is not satisfactory for all clients. Consequently, the practitioner needs to be cognizant of the muscular actions of velopharyngeal closure for speech, muscle rehabilitation procedures, and attributes of potential clients for behavioral treatment. These areas will be examined through the following topics: (1) structure/function relationships of velopharyngeal closure, (2) motor programming of velopharyngeal closure, (3) aims and findings of various types of muscle treatment programs, (4) discussion and rationale of successful muscle treatments, and (5) guidelines for utilizing muscle treatment for the management of clients with velopharyngeal closure deficits.

Structure/Function Relationships of Velopharyngeal Closure

In studying the velopharyngeal mechanism, the paired levator veli palatini muscles are generally considered the primary muscles of closure during speech (Kahane, 1986); however, this is an over simplification. There is also differential activity of the palatoglossus, palatopharyngeus, musculus uvulae, and superior pharyngeal constrictor muscles. That is, the muscles act in coordinated fashion to achieve velopharyngeal closure for speech. Afferent or sensory information is important in the execution of skilled motor movement, and a number of different receptors are located in oral muscles that furnish sensory information before and during skilled movement (Abbs, 1996; Abbs & Cole, 1982; Abbs & Kennedy, 1982; Barlow & Bradford, 1992; Daniloff, Schuckers, & Feth, 1980; Evarts, 1982; Kuehn & Moller, 2000; Pehoski, 1995; Warrren et al., 1989). The incoming sensory or afferent information is processed at different levels of the nervous system to facilitate an efferent or motor system response. Afferent information has different effects on the muscle system such as relaxation, movement or increased range of movement, increase in tone and/or reduction in tone.

Primary sensory receptors that are employed in movement are muscle spindles and Golgi tendon organs (Gardner, 1968; Liss, 1990). Spindles are sensitive to changes in tension brought about by increases in muscle length. Tension created in the tendon by either muscle contraction or stretch is detected by the Golgi tendon organs. The Golgi tendon organs are located at musculo-tendinous junctions. Muscle spindles are found in the velopharyngeal musculature and may provide important sensory information during speech production, but the density of their distribution is the not the same as found in the limbs (Clark, 2003; Daniloff et al., 1980; Kuehn, Templeton, & Maynard, 1990; Liss, 1990). Consequently, muscle rehabilitation techniques utilized for the limbs must be applied cautiously with the velopharyngeal musculature.

Abbs (1996) indicated that perturbation studies provide evidence for the importance of sensory information in making efferent movement adjustments across functional anatomical structures during speech production. For example, disturbances of the lower lip during speech result in compensatory actions of not only the lower lip but also of the upper lip and jaw. Such findings support the notion of sensory feedback and resulting modification across a group of coordinative structures, despite a disturbance to only one of the structures. If the concept of coordinative structures is applied to velopharyngeal closure for speech, activity of the velopharynx could be characterized as a synergistic relationship among the muscles, which are active during closure (Kuehn & Moller, 2000). The muscles act in coordination during speech and function differentially due to the influences of gravity and sensory feedback such as air pressure and airflow ( Tachimura, Hara, & Wada, 1995; Tachimura, Nohara, Hara, & Wada, 1999; Tachimura, Nohara, & Wada, 2000; Tachimura, Nohara, Fujita, Hara & Wada, 2001).

In sum, the paired levator muscles are the primary muscles of closure but other muscles contribute differentially during speech production. The skilled movement of closure for speech is a function of afferent or sensory information that aids in the initiation and guidance of skilled or efferent movement. Research suggests that speech articulators such as the velopharyngeal mechanism operate differentially depending on the demands of the speaking context. That is, the actual participation of different muscles within a group of muscles will vary according to the demands of the speaking task, since the goal is achieving closure with the aim of producing perceptually acceptable speech. Velopharyngeal closure is achieved by the speaker's facility to manage muscle subgroups as coordinative structures because of the differential demands of speech production.

Motor Programming of Velopharyngeal Closure

The motor programming of velopharyngeal activity is an important component in speech production, since a speaker is trying to achieve the goal of perceptually acceptable speech. Caruso and Strand (1999) indicated that speech production is a skilled sensorimotor activity that is under volitional control. As the child develops sensorimotor control, there are increases in the speed of completing motor sequences, decreases in performance variability across tokens and an increase in consistency across movement sequences (Kent, 1999). Researchers have offered different theoretical explanations for the different motor control strategies that speakers use to achieve the goal of correct speech (Moon & Jones, 1991). For instance, flexibility and plasticity are hypothesized as speech motor control strategies that are used by speakers to achieve velopharyngeal closure (Moon & Jones, 1991). Flexibility allows the achievement of a goal within a set of rules that govern the motor control of velopharyngeal closure. The rules are not based on some specific linguistic unit such as a phone or syllable but are flexible holistic motor goals. That is, flexibility permits a normal speaker to make adjustments in the rule structure of a movement pattern while meeting a particular motor goal. There is more than one specific way to achieve a particular production goal. This can be accomplished because the motor system, as previously discussed, operates in coordinative fashion. For example, the coordinated movements of the velum, lateral pharyngeal walls, posterior pharyngeal wall and muscles of the faucial pillars operate to accomplish the goal of perceptually correct speech, and their contributions will vary as a function of a number of different speaking variables.

Plasticity is a hypothetical construct that would allow speakers to change or alter their current rule system in the presence of a problem such as a velopharyngeal closure deficit. That is, if they had the potential to achieve closure for speech, these speakers could create a new rule system that would enable them to overcome the problem. During a period of adaptation, revised motor command goals would be formalized within a new rule system to increase movement toward closure or actually achieve closure for speech. Plasticity is a construct that is a plausible explanation for individuals who exhibit a closure deficit, but they present with perceptually correct speech. McWilliams (1984) discussed the positive compensatory movements of some cleft palate speakers, which allow them to produce perceptually acceptable speech. An explanation of plasticity implies that changes in the rule system allow the speaker to develop new rules over time to achieve appropriate motor goals. That is, the motor pattern reflects a rule reorganization on the part of the speaker to compensate for certain structural deficiencies (Broen, Doyle, & Bacon, 1993; van Lieshout, Rutjens, & Spauwen, 2002; Wulf, McNevin, Shea, & Wright, 1999). Karnell, Folkins, and Morris (1985) reported preliminary data that support the construct of plasticity. The authors examined the oral and velar movements, voicing, and nasal resonance of 4 subjects with repaired clefts. Two of the subjects were judged to have hypernasal speech and 2 were not. The data indicated that the 2 speakers with normal resonance exhibited velopharyngeal movements that were different from expected movement patterns. It was hypothesized by the authors that cleft palate speakers without hypernasality may restructure their motor program in response to the velopharyngeal structural deficits.

In summary, it is hypothesized that a speaker with a closure deficit is attempting to produce perceptually correct speech. The structural constraint forces a speaker to explore different motor programming strategies that may be part of speaker's current system but not employed (Flexibility), or the speaker must develop a new rule system to surmount the problem (Plasticity). There is a small subset of speakers with closure deficits who may benefit from behavioral treatment, because it provides opportunities for them to explore their existent motor command systems and make changes or develop new rules that are not within their motor control system. Caruso and Strand (1999) indicated that important parameters of movement for speech are muscle strength, range of motion, force or muscular tension, and speed. It is likely that all are important in velopharyngeal closure, and an appropriate treatment furnishes opportunities for the speaker to unconsciously engage in tasks that may facilitate flexibility or plasticity (Clark, 2003; Weismer, 1997). Flexibility permits a certain amount of variability within a rule system, whereas plasticity permits the creation of new motor programming strategies in response to previous speech failure. Treatments that provide such opportunities for clients, who have the potential to achieve closure for speech, are likely to result in positive changes for those clients (Tomes, Kuehn, & Peterson-Falzone, 2004).

Aims and Findings of Muscle Treatment Programs in the Treatment of Velopharyngeal Closure for Speech

There are different types of muscle treatment programs that have been and are currently employed by speech-language pathologists in the behavioral treatment of velopharyngeal closure. Some are used in conjunction with speech tasks, while others are utilized in the context of nonspeech oral motor activities (Ruscello, 2004). The aim is to improve different aspects of muscle function such as strength, speed, range of movement and/or skill, so that hypothetically the speaker can modify her/his existing motor program for velopharyngeal closure. The different types of muscle treatment programs currently employed include: (1) active muscle exercise, (2) passive muscle exercise and (3) sensory stimulation (See Table 1). It is to be noted that the efficacy of muscle rehabilitation programs with clients who have closure deficits is limited because of experimental design problems, a small subject population, and the equivocal results that have been reported (Tomes, Kuehn, & Peterson-Falzone, 2004). Current best practice indicates that only a limited number of muscle rehabilitation programs are based on sound theoretical rationale and have empirical data to support their utilization (Clark, 2003). Moreover, there are a limited number of clients who may be candidates for muscle rehabilitation because the majority of clients will require secondary surgical treatment or a speech prosthesis (Kummer, 2001).

Active Exercise

Active muscle exercise is commonly used across a number of disciplines and consists of strength training and stretching. Strength training techniques are employed in cases of muscle weakness (Frontera & Lexell, 2005). Strength is the ability of a muscle to produce appropriate tension for both posture and movement (Smidt & Rogers, 1982). It is a combination of the correct firing of motor units, and the timing of motor unit activation (Shumway-Cook & Woollacott, 1995). Stretching exercise is utilized to either increase or decrease muscle tone.

Strength Training. Strength training programs may employ either isotonic or isometric muscle exercises. Isotonic exercise movements act to change muscle length with muscle tension remaining relatively constant. Isometric exercises are designed to create muscular tension without significantly changing muscle length (Clark, 2005). For instance, an isotonic exercise such as instructing a client to "alternately protrude and retract your tongue and when you protrude your tongue push against the tongue depressor" is an activity for building strength with the tongue musculature. An example of an isometric exercise is having the client hold a tongue depressor between the lips for a specified period of time. Muscle tension is created while keeping muscle length relatively constant. In both examples, the strength training activities would be carried out across a number of practice trials .

A strength building exercise for velopharyngeal closure can be carried out with the use of continuous positive airway pressure (CPAP) (Kuehn1991, 1997; Kuehn et al. 2000). CPAP instrumentation generates air pressure from an external generator source to the nasal cavities that is channeled via a mask. The external pressure and vocal tract pressure generate two pressure heads that are isolated if velopharyngeal closure is achieved. The use of the external pressure source provides a condition where a resistance to velar movement is established. Thus, a client may practice speech production tasks, while the velum is subject to resistance. This enables strength building during speech and is consistent with principles of task specificity (Clark, 2003; Weismer, 2006). That is, the designed exercise activities are explicit to the goal of the muscle rehabilitation program.

Strength training is designed to overload the muscles beyond their normal operating levels, just as an individual engages in weight training through the application of progressive resistance (Tomes, Kuehn, & Peterson-Falzone, 2004). The strength training tasks are carried out for a designated number of training trials across a specified period of treatment, while increasing resistance to movement. Pinet (1998) points out that a majority of functional motor skill activities necessitate a combination of different muscle contractions, so strength training should incorporate a variety of activities that target a specific muscle or muscle group in relation to the target or desired motor skill function. That is, exercise activities should be specific to the goal of the strength-training program (Clark, 2003; Weismer, 2006). Accordingly, if we wished to strengthen an articulator for speech production, the strength training should be in conjunction with a speech task not just in building strength with activities that are only tangentially related to the desired outcome (Kuehn, 1991, 1997).

At a physiological level, strength training influences force, endurance and power (Shumway-Cook & Woollacott, 1995). When a muscle contracts, it creates force or tension and strength training is utilized to heighten muscle tension. Kisner and Colby (1990) state that active exercise also affects endurance, which is the amount of force that can be sustained over a specific time period. Lastly, active exercise is also conducted for the purpose of developing power, the speed with which force is generated. The exercises must be carried out at physiologic levels, which tax the muscle, so that it exceeds its typical operating levels. The neuromuscular result of a successful rehabilitation program is hypertrophy of muscle fibers and collective recruitment of additional motor units (Duffy, 1995; Hodge, 2002).

Stretching. Stretching is the movement of a muscle or muscle group outside of its typical operating range. A corollary to stretching is range of motion (ROM) wherein a muscle or muscle group is moved through its complete range of expected movement, not beyond the range. Stretching exercises are employed to either increase or decrease muscle tone. Muscle tone is the structural scaffold for the execution of skilled motor movement patterns. Physiologically it is the stiffness of a muscle or its resistance to changes in length and is mediated by sensory receptors located in the muscles (Shumway-Cook & Woollacott, 1995). The information is used at different levels of the peripheral and central nervous systems, which include reflexive behavior and higher-level central nervous system functions that mediate motor control. Duffy (1995) writes that tone is a sustained feature of normal muscles, since they are continually in a ready state for movement. Disorders of muscle tone may range from flaccidity or complete loss of muscle tone to spasticity, which manifests in increased muscle tone. In either case tone disorders result in weakness, which adversely affects the execution of skilled movement.

Clark (2003) points out that stretching can be carried out either by the patient (active stretching) or the practitioner (passive stretching). During active stretching exercise, muscle fibers may be subject to quick stretching or slow stretching. Quick stretching results in an increase in muscle tone, while slow stretching results in an inhibition of the stretch reflex, which acts to decrease muscle tone (O'Sullivan, 1988). Duffy (1995) suggests that active stretching may have some benefit in reducing spasticity of the articulators when engaging in exercises such as prolonging maximum tongue protrusion, lip retraction or jaw opening. In the case of velopharyngeal closure, a target might be increasing range of movement through either stretching or range of motion exercises. An example of a stretching exercise is having the client engage in "hard swallowing." Velopharyngeal closure or movement toward closure occurs during dry swallowing, and having the client engage in "hard swallowing" creates the movement of a muscle group outside of its normal operating range. Note that the example is a nonspeech task, and it would not be recommended for improving velopharyngeal closure for speech.

Findings of Active Exercise Studies

Strength training during speech production activities. To date, there is only one treatment that targets velopharyngeal strength development through speech production (Kuehn1991, 1997; Kuehn et al. 2000). Kuehn and his associates used continuous positive airway pressure (CPAP) to apply a resistive load to the velum, while producing speech stimuli. The researchers conducted two separate studies and reported improvement in some of the subjects who underwent the CPAP treatment (Kuehn1991; Kuehn et al. 2000). Some of the subjects were able to increase muscle strength and/or range of motion through systematic resistance practice and improve velopharyngeal closure for speech. See Tomes, Kuehn, & Peterson-Falzone (2004) for additional discussion.

Strength training during nonspeech activities. The use of nonspeech therapeutic exercise has a long history in the profession and has been studied by a number of researchers. Activities such as blowing, sucking, and swallowing have been employed, since velopharyngeal closure occurs in normal speakers during such activities. Since speech and nonspeech activities both require velopharyngeal closure, the treatment assumption is that generalization from nonspeech to speech will occur. However, clinicians need to note that such exercise activities violate the specificity of training principle that was discussed. The results of experiments to date have not generated strong empirical support for nonspeech exercise (Massengill, & Quinn, 1974; Massengill, Quinn, Pickrell, & Levinson, 1968) as a method to increase strength and/or range of motion. A well-controlled experiment by Powers and Starr (1974) studied the effectiveness of blowing, sucking, gagging, and swallowing exercises and found no improvement in closure for the subjects. Currently, such activities remain popular for different speech disorders (Strode & Chamberlain,1997), despite the lack of empirical support (Clark, 2003).

Improving stretching (range of motion) during speech production activities. The correction of compensatory sound system errors such as glottal stops has been shown to positively influence velopharyngeal closure (Henningsson & Isberg, 1986). It may be that the correction of sound system errors facilitates increased velopharyngeal movement through improved range of motion and/or new skill formation. However, the results of investigations in this area are equivocal in terms of reported findings. In the studies examined, subjects with compensatory errors were found to improve sound system production skills, but the acquisition of such skills did not result in improved closure in one group (Shelton, Chisum, Youngstrom, Arndt, & Elbert, 1969). The results of the studies by Ysunza and his associates (Ysunza, Pamplona, & Toledo, 1992; Ysunza, Pamplona, Femat, Mayer, & Garcia-Velasco, 1997) suggest that treatment of compensatory articulations did improve closure for speech; however, the velopharyngeal insufficiency was not totally eliminated. Treatment of sound system errors may be of value in improving velopharyngeal closure for speech (Golding--Kushner, 2001; Peterson-Falzone & Graham, 1990) but additional management of the problem will probably be necessary. Nonetheless, treatment of sound system errors is strongly recommended to develop appropriate oral sound placements, increase intelligibility, improve velopharyngeal movement (Broen, Doyle, & Bacon, 1993) and facilitate future physical management (Golding--Kushner, 2001).

Improving stretching (range of motion) through biofeedback. Biofeedback furnishes subjects with ongoing physiologic performance information that is typically not available to them or has not reached a level of conscious introspection (Davis & Drichta, 1980; Shelton, Paesani, McClelland, and Bradfield, 1975; Wolf, 1983). Generally, instrumentation is used to provide a physiologic signal that a subject uses to modify performance (Roll, 1973; Fletcher, 1972; Fletcher & Higgins, 1980). In the case of velopharyngeal closure, the biofeedback signal enables subjects to engage in treatment activities that may facilitate range of movement and possibly skill development. Typically, subjects are provided with some visual signal such as observation of movement via nasoendoscopy, air pressure or airflow data, or muscle EMG output. The overall results of biofeedback studies support the methodology as a means to improve velopharyngeal closure for some clients (Daly & Johnson, 1974; Ellis, Flack, Carle, & Selley, 1978; Matsuya, Yamaoka, & Miyazaki, 1979; Miyazaki, Matsuya. & Yamaoka, 1975; Moller, Path, Werth, & Christiansen, 1973; Tudor & Selley, 1974; Yamaoka & Furusoawa, 1994; Witzel, Tobe, and Sayler,1988, 1989; Ysunza et al., 1997).

Passive Exercise

Passive exercise is the movement of a muscle or muscle group with assistance by a clinician or through the use of exercise machines (Pinet, 1998). Passive exercise includes passive range of motion (PROM) and passive stretch. The purpose of passive exercise is not to build muscle strength but maintain joint flexibility and soft tissue integrity, enhance vascular circulation, facilitate sensory input to a muscle or muscle group and possibly modify tone (Pinet, 1998). It is unlikely that such exercise would be used to improve velopharyngeal closure for speech, since the purpose is to improve muscle function and passive exercise is typically used to maintain the current status of a muscle or muscle group. Moreover, active muscle exercise is preferred, since current models of motor learning support active muscle exercise for the development of different muscle functions (Clark, 2003). The research findings reported by Kuehn and his associates, as previously discussed, are limited, but support active exercise as a means to improve closure for speech (Kuehn1991, 1997; Kuehn et al. 2000).

Sensory Stimulation

Different sensory stimulation agents are used by clinicians to enhance or stimulate muscle function. They are employed with children who have sound system disorders of a structural etiology that result in a velopharyngeal closure deficit (Ruscello, 2004; Tomes et al., 2004) or exhibit motor speech disorders due to neurological insult (Yorkston et al., 2001). Since these clients present with structural or neurological disorders, sensory stimulation is viewed by some as a method to improve muscle function of the different articulators (Chapman-Bahr, 2001). Sensory agents may include the use of massage, vibration, temperature (hot/cold), tactile stimulation and electrical stimulation. The different types of input are sensed by a variety of mechanoreceptors, proprioceptors, nociceptors, and thermoreceptors that are responsive to changes in muscle length and rate of change in length, muscle tension, joint position, vibration, deep pressure stimulation, skin pressure, pain, temperature, and touch (Shelton, 1989). Sensory agents may have varied effects on the muscle system; such as, relaxation, movement or increased range of movement, increase in tone and/or reduction in tone.

Massage. Massage consists of stroking muscles or tapping muscles (Clark, 2003). Stroking is used to reduce muscle tension and establish a state of emotional relaxation. Tapping muscles stimulates the muscle spindle for the purpose of increasing muscle tone (O'Sullivan, 1988). It is carried out by striking the belly of the muscle with the fingertips during active muscle contraction. Massage is not appropriate for the velopharyngeal muscles because of its reported effect on muscle function. That is, reducing or increasing muscle tone are not appropriate goals for improving closure. In addition, it would be difficult to access the velopharyngeal muscles and apply massage.

Vibration. Vibration is employed to increase or decrease muscle tone. The frequency of vibration will either facilitate or inhibit muscle activity (Bishop, 1974, 1975); high frequency vibration excites muscle activity, but low frequency vibration inhibits muscle activity. Clark (2003) writes that high frequency vibration is employed to elicit a tonic vibratory response (TVR), a reflex contraction that is the result of muscle spindle stimulation. In addition, there is an accompanying decrease in muscle tone of the antagonist muscle through reciprocal inhibition. Thus, high frequency vibration acts to enhance the tone of the agonist and reduce tone of the antagonist. Since the muscles of velopharyngeal closure are not well endowed with muscle spindles, vibration is contraindicated as a treatment and has not been used to date (Clark, 2003).

Temperature and touch pressure. Superficial heat may be applied to muscles to reduce muscle spasm and spasticity. It is also used in cases of bursitis and tendonitis but should not be used where there is edema, swelling or damage to tissue (Lee, Itoh, Yang & Eason, 1990). The application of heat has not been used extensively with the speech musculature; however, cold has been used in the treatment of persons with neuromuscular disorders (Hall, 2001). Johnson and Scott (1993) indicate that icing may be employed with different groups including persons with cerebral palsy, acquired neurological insult such as stroke, and progressive neurological disease like multiple sclerosis. It has been reported that cold may reduce spasticity in muscles, because it acts to decrease nerve conduction speeds (Clark, 2003). Cold in combination with tactile stimulation such as touch pressure to the velum and pharyngeal walls has been used regularly in speech-language pathology as a stimulating agent to improve the speed in triggering the pharyngeal swallow for persons with dysphagia (See Sciortino, Liss, Case, Gerritsen, & Katz, 2003; Logemann, 1998).

Electrical Stimulation. Electrical stimulation is utilized in a number of applications for muscular problems, but it has not been used extensively in speech-language pathology (Clark, 2003; Freed, Freed, Chatburn, & Christian, 2001; Peterson, 1974). Electrical stimulation can be applied to the skin or directly to muscles via electrodes inserted into muscle fibers (Humbert & Ludlow, 2004). When applied to the skin with surface electrodes, electrical stimulation will activate sensory receptors and muscles just below the skin tissue. Most applications of electrical stimulation entail intramuscular stimulation with the stimulation controlled by the patient or delivered automatically. Electrical stimulation is frequently used in combination with other muscle rehabilitation techniques and stimulation is most effective when it is used in combination with strength training and/or functional muscular activities (Pape & Chipman, 2005). It has been employed as a treatment for velopharyngeal closure problems, and it is currently being used for the treatment of dysphagia (Freed et al., 2001; Park, O'Neill & Martin, 1997; Peterson, 1974), but its efficacy has not been established at this time (Humbert & Ludlow, 2004).

Findings of Sensory Stimulation Investigations

There have been a number of investigations that have examined sensory stimulation applied to the velum and/or pharyngeal walls. The sensory stimulation has been applied during speech and nonspeech activities. The rationale underlying such approaches is that the application of sensory stimulation to the structures of velopharyngeal closure will facilitate increased range of movement and possibly build skill. Intuitively, such approaches have face validity, since our current understanding of speech motor skills indicates that sensory feedback is important in the execution of skilled motor movement (Abbs, 1996). However, as Clark (2003) points out, muscle rehabilitation principles based on the limbs may not be appropriate for a majority of the speech musculature, since the distribution of sensory receptors differs.

Sensory stimulation during speech appliance wear. Speech appliances have been used to improve velopharyngeal closure for clients who are not candidates for surgery. Patients are fitted with the intraoral appliances by a prosthodontist, and speech and resonance are monitored by a speech-language pathologist during the fitting and as needed. The appliance needs to be modified with age due to growth factors; however, there are clinical reports in the literature that some clients were able to eliminate the use of appliances after wearing them for different periods of time (Blakeley, 1960; Blakeley, 1964; Blakeley, 1969; Blakeley, 2000; Blakeley & Porter, 1971; Weiss, 1971). The implicit logic underlying the observations is that the appliances furnish continuous sensory stimulation during speech and nonspeech activities, and this acts to improve range of movement, develop skill and possibly build strength. The clinical observations have been subject to experimental scrutiny, but the results do not support the clinical observations (Wolfaardt, Wilson, Rochet & McPhee, 1993; Witt et al., 1995; Shelton, Lindquist, Arndt, Elbert, & Youngstrom, 1971). Moreover, a series of investigations conducted by Tachimura and his associates (Tachimura, Hara, & Wada, 1995; Tachimura, Nohara, Hara, & Wada, 1999; Tachimura, Nohara, & Wada, 2000; Tachimura, Nohara, Fujita, Hara & Wada, 2001) found that levator muscle activity was typically lower when a speech appliance was in place as compared to removal or modification of the appliance. The authors suggested that the lower activity level was a function of reduced force of muscle contraction and range of movement due to appliance placement. When a bleed condition was introduced to simulate a closure deficit, muscle activity increased in an attempt to overcome the closure deficit.

Additional sensory stimulation studies. Different researchers have studied various forms of tactile and electrical stimulation and the overall outcome does not support such treatment (Massengill, Quinn, & Pickrell, 1971; Peterson, 1974; Weber, Jobe, & Chase, 1970; Yules & Chase, 1969). For instance, Tash and her associates (Tash, Shelton, Knox & Michel, 1971) used touch-pressure stimulation to excite the lateral and posterior pharyngeal walls of speakers with cleft palate and normal speakers. The results indicated that both cleft palate speakers and normal speakers were able to develop pharyngeal wall movement as a result of the stimulation, but there was no real change in the pattern of velopharyngeal closure for speech. There was no generalization to speech suggesting that the speakers had the capability to increase pharyngeal wall range of motion, but they did not incorporate that muscular component to the skilled movement pattern of closure for speech. Peterson (1974) studied elevation of the soft palate in response to electrical and tactile stimulation. The electrical current and/or tactile force was measured for each trial. The 20 subjects included 5 who had closure deficits, 5 with repaired cleft palates but acceptable velopharyngeal closure, and 10 subjects with speech problems in the absence of a closure deficit. Subjects underwent cinefluorographic study before and during the stimulation trials. Tactile stimulation did not influence palatal movement, and only 5 subjects exhibited some velar movement in response to electrical stimulation.

Discussion and Rationale of Successful Muscle Treatments

There are numerous studies, which have examined a variety of different muscle rehabilitation treatments. A representative sampling of the studies was presented within a framework of different muscle treatment programs. The overall conclusion of the review is that muscle treatment programs are not an effective treatment methodology for most clients who present with closure deficits. In particular, current literature does not support passive exercise methods or different sensory stimulation agents as viable treatments. However, CPAP (Kuehn, 1997) and various biofeedback techniques were effective for a subset of clients (Ysunza et al., 1997). These are active exercise regimens that target strength building and/or range of motion. The CPAP procedure is a formal strength building technique, while biofeedback is an indirect exercise method.

In terms of altering a motor program by flexibility, it may be that the subgroup of clients who improved with CPAP treatment had the potential for an increase in strength training, which resulted in hypertrophy. The speakers were able to utilize a more normal approximation of velopharyngeal closure that was within the degrees of freedom of their motor programming system. Biofeedback techniques differ, however, in that they provide a physiological index or signal that is not typically available to learner. That is, speakers are provided with information, and instructed to make adjustments in their speech that may or may not be successful. There is exercise across training trials but the primary aim is changing a behavior in response to a physiological signal. Speakers try to formulate appropriate compensations to modify their speech problem. It appears that successful biofeedback clients were able to use the physiological signal and increase range of motion. It is theorized that the subjects engaged in plasticity. That is, they did not alter their current rule system, but instead through experimentation they formulated a new set of rules to achieve their goal of producing perceptually acceptable speech.

It needs to be emphasized to practitioners, who see such clients on an infrequent basis, that some clients may be potential candidates for muscle treatment programs, but not all of the clients will benefit from such treatment (Cohn, 1990; McWilliams, 1985; Ruscello, 2004). The vast majority of clients with closure deficits will require secondary surgical management or a speech prosthesis (Kummer, 2001). If the decision is to treat the closure deficit, the practitioner needs to work in collaboration with other professionals, select subjects who have the potential to improve, utilize a treatment based on sound theoretical rationale, carry out the treatment within a reasonable time frame, and carefully assess client performance.

Guidelines for Utilizing Muscle Treatment

Guideline 1. Engage in collaboration with other professionals.

The clients described herein are generally followed by a cleft palate/craniofacial team for tertiary care and receive primary and secondary care within their community; consequently, collaboration is important in providing quality treatment. For instance, the team speech-speech language pathologist will make treatment recommendations, and consult with the client's school speech-language pathologist who provides primary care services. Grames (2004) emphasized the need for effective collaboration because the primary practitioner who carries out the treatment does not have extensive experience with such clients and the care philosophies underlying the two organizations may also differ. The most important factor in collaboration is keeping an open line of communication, particularly if therapy is to be directed to the behavioral treatment of velopharyngeal closure. The team speech-language pathologist and field practitioner need to communicate frequently if a muscle rehabilitation program is initiated. The client's progress or lack thereof must be examined and results carefully documented.

Guideline 2. Select subjects for muscle treatment who exhibit "velopharyngeal stimulability."

There are no specific criteria to select subjects who may benefit from a behavioral muscle treatment program; however, the clinician should consider the "velopharyngeal stimulability" of the client. This will furnish perceptual information concerning the client's ability to demonstrate closure for speech. Prior to the evaluation, the clinician may prepare the client for the task by having her/him occlude the nostrils with the fingers and produce some practice items. Following practice, the client is given instructions to maintain eye contact and imitate the stimuli produced by the clinician. Stimuli should consist of oral sounds that are made with correct placements. Pressure sounds, particularly unvoiced sounds (plosives, fricatives, and affricates) will provide an assessment of the degree of closure that can be achieved. The clinician should carefully monitor for nasal emission. Voiced sounds, particularly vowels, will provide perceptual information on the resonance balance of the client. The clinician will need to assess resonance quality to determine if hypernasality is present. Subjects who can eliminate or reduce nasal emission and hypernasality are stimulable and candidates for behavioral treatment.

Other clinician (Cole, 1971, 1979; D'Antonio, 1989; Morris, 1992) have proposed that inconsistent nasal emission and/or hypernasality be used as prognostic indicators. Clients found to have inconsistent nasal emission and/or hypernasality might be candidates for a behavioral muscle treatment program. Lotz and Netsell (1987) suggest that the client be probed across various phonetic environments to identify closure that is associated with certain phonetic contexts. If contexts are identified, they would be employed as teaching targets during initial treatment sessions. The authors provided anecdotal information to indicate that closure was acquired on a consistent basis for some patients who demonstrated variability in their speech. In either case, clients identified as exhibiting some potential for closure could be enrolled initially for speech treatment rather than surgical or prosthetic treatment. Van Demark (1979) found that correct production of the plosive cognates /p, b/ in preschool children with cleft palate was a positive predictor of future velopharyngeal competence.

Guideline 3. The duration of muscle treatment should be brief.

Cole (1979) and others (e.g., Kuehn, 1991) indicate that treatment change should occur within a short time period, and therapy should be distributed rather than massed. Specifically, the client should be seen frequently for short treatment sessions within the designated period of treatment, rather than infrequent sessions of some sustained duration. Cole has indicated that a successful client will generally exhibit positive change in behavior after approximately one month of treatment, if the treatment is administered on a frequent basis. For instance, the client might be seen 3 times per week for four weeks with additional practice conducted each night by the client's parents. McWilliams et al. (1990) feel that a three to six month training period should be sufficient to achieve documented change, if the anatomy and physiology will support appropriate closure. Subjects who receive treatment and do not show positive changes in closure for speech after a short period of treatment will more than likely not benefit from extending the treatment period. Hoch, Golding-Kushner, Siegel-Sadewitz and Shprintzen (1986) also indicate that if change occurs, it will do so after a limited amount of treatment. The time periods mentioned by the different authors are estimates; however, they do provide some guidance in planning an experimental treatment. If improvement is not observed, it is unlikely that continued treatment would be helpful for a client, and surgery or prosthetics is indicated.

Guideline 4. Utilize a muscle treatment based on sound theory that has data to support it.

The studies reviewed herein indicate that passive exercise and sensory stimulation treatments were not effective, but active exercise treatments such as CPAP (strength building) and biofeedback (range of motion) were successful in some cases. Data indicates that the clients were able to improve velopharyngeal closure after receiving one of the two treatments (Davis & Drichta, 1980; Kuehn1991). Both treatments are based on a sound theoretical rationale and were subject to empirical examination. In reality, no theory can be completely substantiated, but studies can be designed to verify or challenge a theory (Shuster, 2004). Empirical scrutiny allows a theory to be supported or modified in light of new data and permits a profession to advance its knowledge base (Friel-Patti, 1994). Continued research is needed to further substantiate these theories, but they currently provide a theoretical basis for treatment.

Guideline 5 Employ instrumentation that will assist the client during muscle treatment.

Developments in computer technology and instrumentation allow clinicians to incorporate technology into their management of clients with communication disorders (Masterson & Rvachew, 1999; McGuire, 1995). In addition, costs have been reduced, so that it is feasible to purchase instrumentation or computer hardware/software to be used across a variety of clinical settings. The CPAP equipment is also relatively inexpensive and can be purchased for use with different clients. The same can be said for instrumentation that furnishes various biofeedback signals. It is important that appropriate instrumentation be used, since a preponderance of change has been demonstrated with methods that utilize instrumentation to practice under a resistance load or furnish some physiologic index of performance. Moreover, instrumental measures of acoustic and physiologic variables are important in documenting change with treatment and should be employed with perceptual judgments.

Final Summary

Velopharyngeal closure during speech production enables a speaker to generate appropriate air pressure and flow for the production of oral obstruents and to produce voiced sounds without excessive nasal resonance. Clients with velopharyngeal closure deficits will frequently exhibit articulation and resonance disorders that require treatment. Generally, these clients will undergo secondary surgical procedures or be fitted with a speech prosthesis to correct the structural problem and improve speech production skills. Some practitioners have developed treatments that target the muscles of the velopharyngeal mechanism. The majority of treatments have not been successful, but CPAP and biofeedback treatments have demonstrated positive gains with some clients. Practitioners should be cognizant that there is a limited group of clients who may benefit from a muscle treatment program. If such a treatment is employed, the guidelines discussed herein will provide direction for the practitioner.

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Author Contact Information

Dennis M. Ruscello, Ph.D.

Department of Speech Pathology and Audiology

P. O. 6122

West Virginia University

Morgantown, WV 26505-6122

Phone: 304-293-4242

Email: Dennis.Ruscello@mail.wvu.edu]
Table 1. Different types of muscle rehabilitation

Type of Exercise Rehabilitation Target Type of Muscle
 Exercise

Active exercise
 Strength training Muscle weakness Exercise under
 Isotonic exercise condition of
 Isometric exercise resistance.

Stretching/Range Muscle Tone Increase muscle tone
 of motion via quick stretch.
 Decrease muscle tone
 via slow stretch.

Passive Exercise Maintain joint Movement of muscle
 flexibility, or muscle group
 circulation with external
 assistance.

Sensory stimulation
 Massage Relaxation of Stroking muscles.
 muscles, muscle Tapping muscles
 tone
 Vibration Stimulate or inhibit Low or high frequency
 muscle activity. vibration
 Temperature/Tactile Muscle tone, Apply heat or cold in
 Stimulation movement, spasm, combination with
 sensory deficits, tactile stimulation
 edema, swelling or tactile
 stimulation alone
Electrical stimulation Muscle movement Apply low-level
 electrical voltage
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Author:Ruscello, Dennis M.
Publication:The Journal of Speech-Language Pathology and Applied Behavior Analysis
Geographic Code:1U5WV
Date:Dec 22, 2006
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