Nonverbal praxis in speech pathology: literature review

ABSTRACT

Speech is defined as a motor representation of language, where there is a coordination of three neurological processes: organization of concepts, formulation and symbolic expression; motor act of programming involved in speech production and own motor speech production. The Motor Speech Control, that orders the muscle contraction for the execution of Speech, includes planning, preparing movements and the implementation of plans to result in muscle contractions and dislocations of structures that will culminate in the articulation of Speech. National and international scientific papers envision a new speech playing field for working with a Speech changed with the stimulation of non-verbal Praxis. The aim of this study was to review the national and international literature which the treatment given to Oral Praxis and non verbal and scores the clinical applications in the Speech therapy. We conducted a search in the databases PubMed, Lilacs and Scielo. The 40 selected citations were assessed critically as the objectives, results and conclusions. The articles showed that non-verbal praxis can be stimulated for clinical work with speech, but nevertheless, there is not a description of this speech therapy. Any article referred that the non-verbal Praxis should be worked, not even how to stimulate motor programming for Speech. This study suggests the clinical necessity to create speech therapy tools that include stimulation of non-verbal Praxis to work with the articulation of Speech.

Keywords:
Speech; Articulation Disorder; Motor Skill; Stomatognathic System; Muscles

RESUMO

A Fala é definida como representação motora da Linguagem, em que há a coordenação de três processos neurológicos: organização de conceitos, formulação e expressão simbólica; programação do ato motor envolvido na produção da fala; e sua própria produção motora. O Controle Motor da Fala, que ordena a contração muscular para a sua execução, inclui o planejamento, a preparação de movimentos e a execução de planos para resultar em contrações musculares e deslocamentos de estruturas que culminarão na articulação da Fala. Os estudos científicos nacionais e internacionais vislumbram um novo campo de atuação fonoaudiológica para o trabalho com a fala alterada, com a estimulação da Praxias Não Verbais. O objetivo deste trabalho é revisar, na bibliografia, o tratamento dado às praxias orais e não verbais e pontuar suas aplicações clínicas no âmbito fonoaudiológico. Realizou-se uma busca nas bases de dados PubMed, Lilacs e Scielo. As 40 citações selecionadas foram avaliadas de forma crítica. Os artigos mostraram que a Praxia Não Verbal pode ser estimulada para o trabalho clínico com a Fala, no entanto, não há descrição do trabalho fonoaudiológico, tampouco um detalhamento dos exercícios em sequência que poderiam ser utilizados. Nenhum artigo apontou para o modo como as Praxias Não Verbais deveriam ser trabalhadas, nem mesmo como estimular a programação motora para a Fala. Este estudo propõe a necessidade clínica de criar instrumentos de intervenção fonoaudiológica que incluam a estimulação das Praxias Não Verbais para o trabalho com a articulação da Fala.

Descritores:
Fala; Transtornos da Articulação; Sistema Estomatognático; Destreza Motora; Músculos

Introduction

Speech is defined as motor representation of language, where there is the coordination of three neurological processes: organization of concepts, formulation and symbolic expression; programming of the motor act involved in speech production; and its own motor production of speech. It requires adequate cognitive and phonological developments and full integrity of the neurological system and oral facial structures. The acquisition of phonemes implies perception, organization and production of sounds and has been widely studied^1,2. It is a quick control task where movements must take place in a few milliseconds, requiring high temporal resolution ³. The neurophysiological processing of fluent speech depends on the stability of temporal coordination between motor execution skills and representation of cognitive processing⁴.

In 2004, a scientific publication in ^{_{the Brain(}5} described a new cerebral area to control the articulatory movements relating to speech. By studying the cerebral subjects with apraxia of speech (articulatory planning disorder), through imaging exams, the authors found that the same cerebral area, the insular cortex in the left hemisphere, presented itself with infarction, ie, lesion. From this scientific milestone, this cerebral area becomes recognized as the Dronkers area, a new area involved in the movement of motor planning for speech.

Motor Control which orders the muscle contraction for the execution of speech includes the planning, preparation of movements and execution of plans, aiming muscular contractions and displacement of structures that will culminate in the articulation of speech³. Children are not born with these movements already developed^1,6. Verbal apraxia, which is the sequencing capacity of syllables within words - fluency involved in the sequence of required movements for oral expression - has its functional learning, ie, the interaction with its own speech production that will lead the child to learn them^1,6.

In this sense, phonological acquisition interacts with the development of speech motor control^7,8. Increased accuracy of movements and the development of the phonological system and lexical and cognitive ability result in an intelligible and efficient speech system ^7,9,10.

The scientific papers, representative in the international literature, envision a new phonological field to work with altered speech. In Brazil, in 1996, appearing for the first time in the scientific field was a publication on Non Verbal Apraxia whose authors⁶ expose the need to stimulate this aspect for clinical work with oral language. Broadening the national debate in 2015, the authors show that the praxis alterations of the stomatognathic system are present in individuals with phonological disorders and should be encouraged to correct the clinical framework ^9-11.

Thus, the aim of the present paper is to review, in the national and international literature of the past 16 years, the treatment of Oral and Non Verbal Praxis and score their clinical applications within the phonological scope.

Methods

Performed for the development of the present review, was a search in the PubMed, Lilacs and Scielo databases during the months from March to December 2015. Included were abstracts of articles published in the last 16 years (2000-2015), acquired from open access journals. Also included were book chapters, ASHA guidelines (American Speech and Hearing Association), doctoral theses and master´s dissertations.

In conducting the research, with respect to data collection, four constructs were used: "speech" AND "articulation disorder" AND "rehabilitation of speech AND language disorders" AND "speech praxis".

The construction of "speech praxis" was made using variations with the associations: "oral facial praxis" OR "motor speech disorders" OR "speech praxis" OR "apraxia of speech" OR "developmental motor speech disorders" OR " developmental dyspraxia "OR" developmental verbal apraxia ". After systematic evaluation of the articles found with all changes for the construct of "speech apraxia," the articles were included when presenting relevant content to oral and non-verbal apraxia. The pathology of apraxia was not the focus of the present research, since it sought to reveal the relevant content to the normality of apraxia and not the pathology. Undoubtedly, the clinical data regarding the pathology elucidated important aspects, and some of them will be cited and may corroborate the central ideas of the present study.

The survey was conducted in stages. First, constructs were sought separately, each with its due keywords. From the results of each, a new search with the combination of other constructs was performed. Such words were selected in specific articles of the area.

Citations in languages other than English, Spanish and Portuguese were excluded, as well as those repeated by overlapping keywords. Evaluated were the texts which effectively related to the proposed research.

Identified were 67 valid citations for speech studies. In the first analysis, 26 texts were excluded, which were repeated by overlapping. Of the remaining 41, only 30 presented speech data, apraxia and rehabilitation. Book chapters (4), ASHA guidelines (American Speech and Hearing Association) (1), scientific conference proceedings (2) and master's dissertations (3) were also included. Therefore, the citations included in the study were 40.

The 40 selected citations were critically assessed regarding the objectives, number and gender of participants, age, criteria and evaluation methods, results and conclusions. It included articles related to the presence of information and definition of praxic difficulties in different groups, articles pointing to the need for stimulation of Non Verbal Apraxia in clinical phonological therapy with speech and articles that expose different protocols for evaluating apraxia.

Literature Review

The search for texts in databases was performed, in full, by the researcher, in order to minimize possible losses of citations (Figure 1).

Figure 1:
Article distribution in database and key words (decs)

From the corpus analyzed with respect to the literature, several aspects were relevant to define the route of contributions, with a view to the production of the present article (Figure 2).

Figure 2:
Scientific literature selected for the theme non verbal praxis

Speech Motor Control is defined as "the set of systems and strategies that control the production of speech" ³. It includes the planning, preparation and execution of movements that result in muscle contractions and structure displacement. The input to the motor control system is a speech phonological representation of language, especially a sequence of abstract units, such as phonemes. Speech motor control output is a series of articulatory movements that have the function of transmitting destined linguistic messages^1,3,4. In fact, speech motor control must be understood in relation to the total communication process of human speech, including phonological processes and motors, a position reaffirmed in the present article ^{4,9,10,21,22,26,27,31,32,37}. Defined as the Dronkers area was the cerebral area for the coordination of articulatory movements of speech⁵. Speech Motor Control is developed differently from the initial speakers and depends on the interaction with the phonological development^{4,6,19,22,27,28}.

In this perspective, articles were selected proposing stimulation of Speech Motor Control to adapt to patterns in patients with deviations in oral verbal production, with or without diagnosed neurological conditions, since it is part of this control^{6,8-10,13,15,20,21,25,31,33,36}, without excluding other involved aspects^1,3,6,21,24. A recent study extends the work with speech, training and strengthening the network of reading and writing to children with apraxia³⁵. In the literature, there are specific references that Non Verbal praxia sequences of lips and tongue movements should be encouraged to work with speech, even without neurological changes^{6,10,16,26,29,30,31,33 36}, and there is the effectiveness of a muscle approach to work with it^8,33,36.

Scientific studies indicate that the praxic difficulties in their groups, and especially in neurological disorders, were also included in the present research^{1,2,7,9,11,15,16,18,20,22,24,32}. The most mentioned diseases were Parkinson's and Alzheimer's which were are also defined as apraxia, since there is a basic neurological disorder that already aggravate the production of speech. Articles that dealt specifically with the work of speech apraxia were discarded, since the objective of the present study was whether the stimulation of work of Non-Verbal praxis is relevant in cases of speech alterations without neurological disorders. However, existing in studies of apraxia, is a report that stimulation of speech motor control should be part of the scope of therapy with those patients diagnosed with compromises, with significant referred results^{7,13,15,20,22}.

Before the discussion of the clinical studies with praxis, cited in the present review, evident were the articles inserted in the bibliography, which is proposed to evaluate them. There are articles with protocols for evaluation and review which aspects are relevant to the evaluation process of praxis^2,17,34. Among these, we can mention: performing praxis or oral facial movement sequences of oral facial movements, parallel movements involving more than one oral facial structure, articulation of simple phonemes, joint complex phonemes and syllables, in addition to spontaneous speech.

The phonological approach to clinical work with speech alterations should include auditory aspects, involving phonological awareness, and motor aspects ^{6,8,10,12,15,20,26,29,30,33}. Specific topics for this study^{6,8,10,12,29,31,33,36} were cited. However, there is no description of the present study, nor a breakdown of the sequence of exercises could be applied. No article detailed the way in which Non Verbal praxis should be worked, not even how to stimulate motor programming for speech.

Although not cited in "Figure 2", there are studies that disagree with the findings that stimulation of oral and non-verbal apraxia is beneficial to clinical work with speech. It was thought appropriate to quote them in this discussion^38-40. For the authors, the hypothesis that motor learning is facilitated when broken down into smaller units, in the case of speech, is not valid. This separation into parts affects the correct production, causing a break in the necessary interaction between them for proper execution. The motor and linguistic aspects, in this view, are combined in an additive way for coordination of speech.

The literature proved itself undeniable regarding the fact that when it elects the specificity of praxis movement for clinical work with speech, focusing it with one of the parts to be encouraged, it allowed to consider, which is fundamental, the relevance of the "whole", the sum of the motor and phonological aspects to work with language and speech.

Conclusion

Speech Motor Control includes planning, preparation and execution of movements that result in muscle contraction and displacement of structures for the articulation of speech. Non-Verbal Praxis can be stimulated for clinical work with speech. However, there is no description of this phonological therapy, nor a breakdown of exercises in sequence that could be applied. We suggest encouraging the publication of case study types of work or researches and publication of language intervention methods that include stimulation of Non Verbal Praxis for the adequacy of speech.

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Publication Dates

• Publication in this collection
  Sep-Oct 2016

History

• Received
  13 June 2016
• Accepted
  08 Aug 2016