Speech Therapy and Phoniatrics

Summary

Speech therapy and phoniatrics explore the therapeutic and medical aspects of improving the lives of people with communication disorders. Applications include games or activities designed to give a person more opportunities to practice and pronounce specific sounds correctly. Other communication disorders may require surgical intervention or botulinum toxin injections.

Definition and Basic Principles

Speech therapy and phoniatrics are overlapping fields that evaluate, prevent, and treat communication disorders, including any defect, disease, or deficit that compromises one's ability to use and understand spoken or written language. Communication disorders are any anatomical, physiological, or neurological disorder that negatively affects a person's voice, articulation, language fluency, respiratory system, vocal tract resonancy, use of language, quality of speech, or ability to hear and swallow.

Speech therapy improves speech and communication skills by altering physical, cognitive, and emotional behaviors and environments that influence the vocal tract during speech. The field has many specializations. Not all speech therapists work with people who have communication disorders. Some work with actors and singers to improve the quality and strength of their voices. Speech therapists, especially within the United States, are required to have a Master's degree in the field.

Phoniatrics is the medical evaluation and treatment of any disease or disorder that affects communication. Phoniatricians are trained at medical facilities and have a comprehensive knowledge of many communication disorders. The field of phoniatrics is prevalent in Europe but not common in North America.

Background and History

The study of language and speech communication disorders was originally derived from two medical disciplines: otorhinolaryngology (the study of the ears, nose, and throat) and internal medicine. A major breakthrough in understanding and exploring voice production occurred in the mid-1850s when Manuel Garcia, a Spanish voice teacher, became widely recognized as the first person to see his own vocal folds with the assistance of a dental mirror. Following Garcia's demonstration before the Royal Society of Medicine, medical interest in the larynx and the pathology of the vocal folds increased. The ability to see the larynx and the vocal folds altered the world of laryngology and also general knowledge about the voice. Before that discovery, most diseases or disorders of the larynx had to be viewed and studied postmortem after several such diseases had proven fatal.

Several decades later, in 1905, voice, speech, and language pathology were finally recognized as a separate academic discipline. One of the driving forces behind this movement was German physician Hermann Gutzmann, recognized as the father of voice and speech-language pathology.

The American Speech-Language-Hearing Association was founded in 1925. However, at the time, most American speech therapists were interested in communication disorders that dealt with aphasia, articulation, and fluency; there was little interest in disorders of the voice and larynx. In the late 1930s and early 1940s, the Nazi regime forced many European phoniatricians and voice experts to emigrate to the United States. These emigrants initiated US interest in voice pathology, which became a more prominent field of study in the 1980s.

How It Works

Ingredients for Verbal Expression. Verbal communication requires both anatomical and neurophysiological processes used during respiration, phonation, resonation, articulation, and perception. To produce speech in English, air flows from the lungs and passes through the vocal tract; this is known as egressive airflow. Some languages use ingressive airflow (air external to the body flows into the oral cavity) to produce speech sounds. An example of this type of airflow is “tsk, tsk,” which is used to communicate disapproval in English.

Changes in the vocal tract account for the different speech sounds humans can produce. These changes include positions of the vocal folds, the velum (soft palate), and the articulators (lips, teeth, tongue, and palate) within the oral cavity. The airstream flowing from the lungs is first modified in the larynx, where the vocal folds are located. If the vocal folds are open, the air will pass through freely; this occurs when a person breathes or pronounces a voiceless sound such as /p/ or /t/. If the vocal folds are pressed loosely together, air will pass through them, causing the vocal folds to vibrate and create a voiced sound such as /b/ or /d/. Complete closure of the vocal folds creates a glottal stop—the airflow is completely stopped, as heard in the pause between “uh” and “oh” when saying “uh-oh.” Additional vocal fold alterations produce vocal qualities that are breathy or creaky. These vocal states are distinguishing speech features in some languages.

Next, the position of the velum or soft palate determines the nasality of an utterance. When the velum is pressed against the back wall of the pharynx, airflow is blocked from traveling up the nasal cavity. Air then flows out of the mouth, creating oral sounds such as /p/. Nasal sounds, such as /m/ and /n/, occur when the velum is lowered, and air flows through both the oral and the nasal cavities but mainly exits out of the nostrils.

Finally, the placement of articulators modifies the speech airstream before it exits the vocal tract. To create the sounds /p/ and /b/, one presses the lips together and then quickly releases them. To create the sound /s/, one presses the tip (or the front of the tongue) up against the back of the lower teeth.

People rarely make single sounds separate from each other unless they are practicing speech exercises or telling someone to “Shhh.” Verbal expression requires users to blend and sequence different sounds together to create words; those words are then sequenced to form larger utterances and sentences.

Being able to do all of this relies on language-specific cognitive abilities and many physiological systems, including the skeletal, articular, muscular, digestive, vascular, nervous, and respiratory systems. Because language is so complex, many things can go wrong. This is when a speech therapist or phoniatrician comes in.

Determining an Individual Intervention Plan. When there is a communication issue, the speech therapist or phoniatrician must create an individual intervention plan. Evaluation of a person's communication skills, including sounds that are present and absent, helps determine the type of speech problem, the anatomical location of the problem, and also any communication strengths. This information can then be used as a baseline to compare against future speech. It is important to note that the absence of a communication skill does not mean the skill cannot be performed.

Interviews, observations, and statistically sound tests give the therapist insight into the communication disorder being addressed. Information gathered from and collaboration with the individual and their family is important to determining intervention goals and creating a care plan that is culturally sensitive and unique to the person.

Developing and Implementing Interventions. Therapy and intervention largely strive to improve a person's intelligibility, accuracy in making speech gestures, ability to use communication correctly, and ability to monitor their own verbal behaviors (actions needed to formulate speech) and outputs.

The best interventions or care plans are based on an individual's strengths and goals to improve communication. In addition to knowledge of the client and their values or needs, therapists use knowledge of typical and disordered communication—how communication disorders affect typical communication, knowledge of scientific research on various treatment methods, and knowledge gained from previous experience working with people who have similar disorders.

Case studies, research from similar fields (including psychology, medicine, and linguistics), knowledge of child development, and knowledge of language processes help determine potential intervention methods.

Applications and Products

Therapeutic Approaches to Intervention. Many approaches to intervention are based on different aspects of child development and theories on language processing. Three major approaches are used: behaviorist, linguistic-cognitive, and social-interactionist.

The behaviorist approach is based on operant conditioning, in which a behavior is modified by rewards or consequences. Rewards, such as stickers, toys, and praise, are used during speech therapy to encourage young clients to reach the target communication skill.

When a patient is taught general linguistic rules, the linguistic-cognitive approach is used. For example, the past tense in English is most often marked by the suffix “-ed.” This approach emphasizes learning through active interaction with the environment. The client takes an active role, and the therapist simply provides different environments for the person to practice and learn linguistic rules.

The importance of socialization is emphasized in the social-interactionist approach, particularly scaffolding or learning from a more experienced person. The therapist carefully monitors what the client can do on their own and what the person can do with the help of others to offer only necessary assistance.

Medical Approaches to Intervention. Medical intervention methods for communication disorders include prescription drugs, injections (usually to the vocal folds), and surgery performed by an otorhinolaryngologist or laryngologist.

Application of Therapeutic and Medical Approaches. Depending on the underlying conditions, various therapies and medical approaches are used to aid communication disorders.

People affected by dementia often have trouble naming objects, people, and sounds. Medications given to improve memory can also improve this related speech disorder. Speech therapy is also beneficial; the client can practice communication skills, and family and friends can be taught how to give subtle verbal cues to the client without causing added frustration.

Treatment for reading disabilities emphasizes phonological awareness and development. Verbal, visual, and hands-on games and activities help the client break down both spoken and written words into syllables and individual sounds and letters. Educators, reading specialists, and speech therapists use phonics to improve the individual's ability to recognize different sounds and letters.

Therapies for children with phonological or articulatory communication disorders also emphasize phonological awareness. Speech and communication specialists will concentrate on making the speaker aware of minimal pairs or word pairs, such as “bad” and “tad,” which have only one different sound, in this case, the /b/ and /t/. The person realizes that the intended meaning can be easily misconstrued if they do not properly pronounce each individual sound. Verbal and intraoral tactile cues are given to assist those who cannot pronounce specific sounds.

Like all forms of therapy, voice therapy is based on setting and achieving short- and long-term goals. A few goals of voice therapy are to strengthen vocal behaviors that have or potentially can have a negative effect on the voice, to teach and promote appropriate vocal behavior such as breathing properly and speaking at a healthy volume, and to teach the person different vocal behaviors, for example, speaking at an audible volume. Exercises in breathing, loudness reduction, and relaxation teach people how to use their voices appropriately. Various computer programs can identify incorrect speech behaviors and also measure improvement over time.

Medications. Spasmodic dysphonia negatively affects the movement of the vocal folds. Routine botulinum toxin (Botox) injections are a common treatment for this disorder. These injections temporarily and partially relieve the problems by weakening the laryngeal muscles so that they have partial movement. The injections make it easier for the person to use verbal expression, although the voice may not sound “normal.” On the negative side, the person has to receive an injection every few months.

Injections are also used to help people with unilateral or one-sided paralysis of the vocal folds. Because individuals who have vocal fold paralysis sometimes experience spontaneous recovery, injections are usually not given for the first six to nine months. In addition to botulinum toxin, specialists also inject gelfoam paste, fat, bovine collagen, or polydimethylsiloxane (a substance originally used in plastic surgery and urology). In the United States, laryngeal injections are performed by otorhinolaryngology or laryngology specialists.

Surgical Options. Phonosurgery is the general term used to describe surgical treatment of voice disorders. A common surgery, thryoplasty, reconstructs the thyroid cartilage to change the tension and position of the vocal folds. Another surgery, laryngectomy, involves the removal of the larynx, which is where the vocal folds are located. People who have had this surgery must use a device to speak. Another procedure, called a tracheosophageal puncture, connects the trachea to the esophagus with a small device. To speak, the person manipulates air within the esophagus instead of the larynx. Muscular action compresses the air in the esophagus and forces it through the top of the closed esophagus. As a result, the pharyngoesophageal region vibrates to create voicing.

Careers and Course Work

To become a speech therapist in the United States, one needs to obtain a Master's degree in the field. In many other countries, a Bachelor's degree is accepted. Basic coursework includes topics in child development, linguistics, psychology, physics and acoustics, physiology, anatomy, and neurology. Other qualifications vary by state. Many states require speech therapists to complete a minimum of four hundred hours of clinical experience, a thirty-six-week clinical fellowship, and the speech therapy Praxis exam to earn a clinical competence certificate (C.C.C.).

Related professions include otorhinolaryngology, laryngology, neurology, augmentative and alternative communication, assistive technology, and audiology (ear and hearing specialist). Augmentative and alternative communication and assistive technology use communication devices for people who cannot express themselves intelligibly (comprehensively) through verbal speech or have severe difficulty doing so. Augmentative and alternative communication users include people with amyotrophic lateral sclerosis, autism spectrum disorder, or cerebral palsy.

Social Context and Future Prospects

Like other medical specialists, speech therapists and phoniatricians constantly seek new, more efficient therapies and treatments. Scientists and researchers also regularly reevaluate the effectiveness of treatments. During the COVID-19 pandemic, telehealth became a necessity, and its use continued following the pandemic. Telehealth speech therapy was believed to be as effective as in-person therapy and a promising development for people in rural areas. Artificial intelligence has made speech evaluation more objective and allowed for more personlization in treatment plans. Technology, such as iPads, applications, and virtual reality, have also played a key role in the speech field in the twenty-first century. 

However, intervention, especially with the vocal folds, does not perfect speech and communication. Even after treatment, many people with communication and voice disorders will still have distinct and possibly unusual vocal qualities. However, as technology and science evolve, so will this field, thereby creating more opportunities for resolving communication disorders.

Bibliography

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