The main directions of correctional work for dysarthria

Dysarthria is a violation of the pronunciation aspect of speech, which occurs as a result of organic damage to the central nervous system. At the Yusupov Hospital, a multidisciplinary approach is used to restore speech in patients suffering from various types of dysarthria. Neurologists, psychologists, speech therapists, and rehabilitation specialists take part in the rehabilitation process. Each patient is given an individual dysarthria correction program.

The following basic principles of correctional work for dysarthria are distinguished:

• A complex approach;
• Systematicity and regularity;
• Early start of restoration and correction work;
• Development of all components of speech (vocabulary, grammatical structure, coherent utterance);
• Development and formation of all mental activity of the patient;
• Individual approach and formation of motivation for classes.

An important principle of correctional work for dysarthria is the early start of rehabilitation and correction work. This is especially important for dysarthria that developed in patients with stroke, after traumatic brain injury, congenital dysarthria and speech impairment in patients suffering from cerebral palsy. Work to overcome dysarthric disorders is always systematic, long-term, painstaking, and regular. The speech therapy work of specialists at the Yusupov Hospital is aimed not only at correcting pronunciation, but also at the development and formation of the patient’s entire mental activity and the development of all other components of speech (vocabulary, grammatical structure, coherent utterance).

The course of speech therapy work is long, it takes several years. Specialists at the Yusupov Hospital build a whole system of relationships with the patient and his family and use stimulation methods. When working with patients, various game techniques, incentive measures, and stimulation of the volitional components of the psyche are used in an effort to improve speech.

The main directions of correctional work for dysarthria are as follows:

• Development of phonemic attention and perception;
• Formation of speech breathing;
• Overcoming voice disorders;
• Work on the prosodic side of speech (rhythm, tempo, intonation);
• Development and formation of facial and articulatory motor skills;
• Production of sounds;
• Formation and development of general motor skills and fine motor skills of the hands.

In case of identified violations of vocabulary and grammatical structure, the speech therapist works in parallel in these areas.

Correction stages

The first stage of correction of erased dysarthria is preparatory. Work to overcome speech disorders begins with overcoming the layers and secondary phenomena that interfere with correct pronunciation:

• Excessive drooling;
• Muscle passivity;
• Deficiencies in phonemic awareness and perception;
• Preparing muscles for the formation of articulatory patterns.

At the second stage, the speech therapist’s work is aimed at overcoming the main disorder – phonetic speech deficiencies. It lies in the production of sounds. The third stage is the inclusion of the patient in active communication.

Natural exercise of the muscles of the oral region is the act of eating. Training the masticatory muscles using a natural process is given attention from an early age. A patient who has suffered a stroke or traumatic brain injury, suffering from degenerative diseases of the nervous system or cerebral palsy, is taught chewing techniques, especially chewing with the mouth closed, and is taught to alternately chew on the right and left sides of the mouth.

If older children exhibit early reflexes (sucking), work is carried out aimed at inhibiting delayed reflexes. Speech therapists use a mechanical obstacle to prevent unnecessary movement. The speech therapist fixes the muscles of the mouth with his hands, and fixes involuntary movements of the tongue with a spatula or biting the tongue with his teeth. To remove friendly movements, the chin is fixed with the hand of a speech therapist. The reflex of the relationship between the movements of the mouth and hand can be inhibited during articulation gymnastics by fixing the child’s hands with the hand of a speech therapist.

At the same time, they develop the ability to voluntarily control their muscles. The patient is given a goal, encouraged to control movements, uses visual control, and encourages the slightest success. It is difficult to slow down reflexes in the oral area, as this area is vital and sensitive. Not only the muscular system is highly developed in it, but also all types of sensitivity: tactile, taste, temperature.

To overcome drooling, the patient is taught to swallow saliva. For this purpose, massage the masticatory muscles, induce swallowing movements, tilt the head back and offer to swallow saliva. To stimulate chewing movements, you can give the patient a cookie or roll and teach him to chew in front of a mirror, alternating chewing with swallowing.

The patient is taught to voluntarily close his mouth through passive movements of the lower jaw, which are initially performed by a speech therapist. He places his hand under the lower jaw, under the chin, puts the other on the patient’s head and closes the jaws with light pressure. Then the patient is taught to perform this movement independently on command: open your mouth, close your mouth.

The patient is taught techniques of voluntary relaxation - relaxation. The training begins with general relaxation. They are taught to voluntarily relax the muscles of the upper and lower extremities, then the neck and head. Develop the ability to distinguish between tension and relaxation and regulate according to instructions. Exercises are carried out in a playful way.

To relax, stroking, vibration and other relaxing massage techniques are used. Acupressure is used for the same purpose. This work is carried out by massage therapists at the Yusupov Hospital after consultation with a neurologist and rehabilitation specialist.

Where to start treatment

Treatment of any disease must begin with a correct diagnosis. A young patient is first referred to a neurologist for consultation. After the examination, the specialist, if necessary, prescribes examinations :

• EEG;
• electromyography;
• MRI;
• electroneurography;
• transchannel magnetic stimulation.

After the diagnosis is established, the child is sent to a speech therapist who conducts special speech therapy tests. They allow you to determine the degree of the disease and its form. Subsequently, a neuropsychiatrist and a defectologist are involved in the process.

There are four degrees of the disease :

• 1st degree – the diagnosis is established only through special tests by a competent specialist;
• 2nd degree – speech is understandable, but has minor defects;
• 3rd degree – only close relatives understand the speech;
• 4th degree – speech is incomprehensible or absent.

Depending on the degree of the disorder, the specialist prescribes treatment and carries out corrective measures.

Speech therapy massage according to Prikhodko

Speech therapy massage is an active method of mechanical influence for dysarthria. It is used in cases where there is a violation of the tone of the articulatory muscles, changing the condition of the muscles of the peripheral speech apparatus. It indirectly helps improve the pronunciation side of speech.

Speech therapy massage according to Prikhodko is carried out at all stages of corrective action. It is used in the initial stages of rehabilitation, when the patient still does not have the fundamental ability to perform certain articulatory movements. Differentiated speech therapy massage at the Yusupov Hospital is carried out by a senior exercise therapy instructor who has knowledge of the anatomy and physiology of muscles and the speech apparatus, has undergone special training, and is fluent in massage techniques.

Rehabilitation specialists teach those caring for a patient with dysarthria basic massage techniques and passive articulatory gymnastics. Differentiated speech therapy massage is necessary to normalize the muscle tone of the articulatory apparatus, and in more severe cases, to reduce the degree of manifestation of motor defects of the articulatory muscles:

• Hyperkinesis (excessive violent motor acts that occur against the will of the patient);
• Spastic paresis,
• Ataxia (impaired coordination of movements not associated with muscle weakness);
• Synkinesia (additional movements that occur involuntarily during basic functional movements).

With its help, they activate those muscle groups of the peripheral speech apparatus that cannot fully contract, or activate new muscle groups that were previously inactive, stimulate proprioceptive sensations, and reduce the secretion of saliva. Speech therapy massage strengthens the pharyngeal reflex, prepares conditions for the formation of voluntary, coordinated movements of the articulation organs.

The essence of speech therapy massage is the application of mechanical irritations:

• Stroking;
• Tingling;
• Kneading;
• Rubbing;
• Vibrations;
• Effleurage.

The differentiated use of various massage techniques allows rehabilitation specialists at the Yusupov Hospital to reduce muscle tone in case of muscle spasticity or increase it in case of hypotonia of the articulatory muscles. Subsequently, the patient develops and carries out voluntary (active), coordinated movements of the articulation organs. Speech therapy massage is performed in the area of ​​the muscles of the head, neck, and upper shoulder girdle. Particular attention is paid to the muscles of the peripheral speech apparatus (tongue, lips, soft palate and cheeks), as they ensure the production of speech.

Dysarthria. System of correctional pedagogical work; methodological development in speech therapy on the topic

Dysarthria. System of correctional and pedagogical work

Dysarthria is a violation of the pronunciation aspect of speech caused by insufficient innervation of the speech apparatus.

The leading defect in dysarthria is a violation of the sound pronunciation and prosodic aspects of speech associated with organic damage to the central and peripheral nervous systems.

Dysarthria is a Latin term, translated as a disorder of articulate speech - pronunciation (dys - violation of a sign or function, artron - articulation). When defining dysarthria, most authors do not proceed from the exact meaning of this term, but interpret it more broadly, referring to dysarthria as disorders of articulation, voice formation, tempo, rhythm and intonation of speech.

Sound pronunciation disturbances in dysarthria manifest themselves to varying degrees and depend on the nature and severity of damage to the nervous system. In mild cases, there are individual distortions of sounds, “blurred speech”; in more severe cases, distortions, substitutions and omissions of sounds are observed, tempo, expressiveness, modulation suffer, and in general the pronunciation becomes slurred.

With severe damage to the central nervous system, speech becomes impossible due to complete paralysis of the speech motor muscles. Such disorders are called anarthria (a - absence of a given sign or function, artron - articulation).

Dysarthric speech disorders are observed with various organic brain lesions, which in adults have a more pronounced focal nature. In children, the frequency of dysarthria is primarily associated with the frequency of perinatal pathology (damage to the nervous system of the fetus and newborn). Dysarthria is most often observed in cerebral palsy.

Less severe forms of dysarthria may be observed in children without obvious movement disorders, who have suffered mild asphyxia or birth trauma, or who have a history of other mild adverse effects during fetal development or childbirth. Dysarthria is often observed in the clinic of complicated mental retardation.

The pathogenesis of dysarthria is determined by organic damage to the central and peripheral nervous system under the influence of various unfavorable external (exogenous) factors acting in the prenatal period of development, at the time of childbirth and after birth. Among the causes, asphyxia and birth trauma, damage to the nervous system due to hemolytic disease, infectious diseases of the nervous system, traumatic brain injuries, and less often - cerebrovascular accidents, brain tumors, malformations of the nervous system, for example congenital aplasia of the cranial nerve nuclei, are important. (Moebius syndrome), as well as hereditary diseases of the nervous and neuromuscular systems.

Clinical and physiological aspects of dysarthria are determined by the location and severity of brain damage. The anatomical and functional relationship in the location and development of motor and speech zones and pathways determines the frequent combination of dysarthria with motor disorders of varying nature and severity.

Sound pronunciation disorders in dysarthria occur as a result of damage to various brain structures necessary to control the motor mechanism of speech. Such structures include:

• peripheral motor nerves to the muscles of the speech apparatus (tongue, lips, cheeks, palate, lower jaw, pharynx, larynx, diaphragm, chest);

• the nuclei of these peripheral motor nerves located in the brain stem;

• nuclei located in the brainstem and in the subcortical regions of the brain and carrying out elementary emotional unconditioned reflex speech reactions such as crying, laughing, screaming, individual emotional-expressive exclamations, etc.

The defeat of the listed structures gives a picture of peripheral paralysis (paresis): nerve impulses do not arrive to the speech muscles, metabolic processes in them are disrupted, the muscles become sluggish, flabby, their atrophy and atony are observed, as a result of a break in the spinal reflex arc, the reflexes from these muscles disappear, areflexia.

The motor mechanism of speech is also provided by the following brain structures located more highly:

• subcortical-cerebellar nuclei and pathways that regulate muscle tone and the sequence of muscle contractions of speech muscles, synchrony (coordination) in the work of the articulatory, respiratory and vocal apparatus, as well as the emotional expressiveness of speech. When these structures are damaged, individual manifestations of central paralysis (paresis) are observed with disturbances in muscle tone, strengthening of individual unconditioned reflexes, as well as a pronounced violation of the prosodic characteristics of speech - its tempo, smoothness, volume, emotional expressiveness and individual timbre;

• conducting systems that ensure the conduction of impulses from the cerebral cortex to the structures of the underlying functional levels of the motor apparatus of speech (to the nuclei of the cranial nerves located in the brain stem). Damage to these structures causes central paresis (paralysis) of the speech muscles with an increase in muscle tone in the muscles of the speech apparatus, strengthening of unconditioned reflexes and the appearance of reflexes of oral automatism with a more selective nature of articulatory disorders;

• cortical parts of the brain, providing both more differentiated innervation of the speech muscles and the formation of speech praxis. When these structures are damaged, various central motor speech disorders occur.

CLASSIFICATION OF DYSARTHRIA

It is based on the principle of localization, syndromological approach, and the degree of intelligibility of speech for others. The most common classification in Russian speech therapy was created taking into account the neurological approach based on the level of localization of damage to the motor apparatus of speech (O. V. Pravdiva and others).

The following forms of dysarthria are distinguished: bulbar, pseudobulbar, extrapyramidal (or subcortical), cerebellar, cortical.

The most complex and controversial in this classification is cortical dysarthria. Its existence is not recognized by all authors. In adult patients, in some cases, cortical dysarthria is sometimes confused with the manifestation of motor aphasia. The controversial issue of cortical dysarthria is largely associated with terminological inaccuracy and the lack of one point of view on the mechanisms of motor alalia and aphasia.

According to the point of view of E. N. Vinarskaya (1973), the concept of cortical dysarthria is collective. The author admits the existence of its various forms, caused by both spastic paresis of articulatory muscles and apraxia. The latter forms are designated as apraxic dysarthria.

Based on the syndromological approach, the following forms of dysarthria are distinguished in relation to children with cerebral palsy: spastic-paretic, spastic-rigid, spastic-hyperkinetic, spastic-atactic, ataxic-hyperkinetic (I. I. Panchenko, 1979).

This approach is partly due to the more widespread brain damage in children with cerebral palsy and, in connection with this, the predominance of its complicated forms.

Syndromological assessment of the nature of articulatory motor disorders poses a significant challenge for neurological diagnosis, especially when these disorders manifest themselves without clear motor disorders. Since this classification is based on a subtle differentiation of various neurological syndromes, it cannot be carried out by a speech therapist. In addition, a child, in particular a child with cerebral palsy, is characterized by a change in neurological syndromes under the influence of therapy and the evolutionary dynamics of development, and therefore the classification of dysarthria on a syndromic basis also presents certain difficulties.

However, in a number of cases, with a close relationship in the work of a speech therapist and a neurologist, it may be advisable to combine both approaches to identifying various forms of dysarthria. For example: complicated form of pseudobulbar dysarthria; spastic-hyperkinetic or spastic-atactic syndrome, etc.

A classification of dysarthria according to the degree of speech intelligibility for others was proposed by a French neurologist. G. Tardier (1968) in relation to children with cerebral palsy. The author identifies four degrees of severity of speech disorders in such children.

The first, mildest degree, when sound pronunciation disorders are detected only by a specialist during the examination of the child.

The second is that pronunciation violations are noticeable to everyone, but speech is understandable to others.

Third, the speech is understandable only to the child’s loved ones and partially to those around him.

The fourth, most severe, is the absence of speech or the speech is almost incomprehensible even to the child’s loved ones (anarthria).

Anarthria refers to the complete or partial absence of the ability to produce sounds as a result of paralysis of the speech motor muscles. According to the severity of its manifestations, anarthria can vary: severe - complete absence of speech and voice; moderate - the presence of only vocal reactions; easy - the presence of sound-syllable activity (I. I. Panchenko, 1979).

CHARACTERISTICS OF DIFFERENT FORMS OF DYSARTHRIA

Cortical dysarthria is a group of motor speech disorders of different pathogenesis associated with focal damage to the cerebral cortex.

The first variant of cortical dysarthria is caused by unilateral or, more often, bilateral damage to the lower part of the anterior central gyrus. In these cases, selective central paresis of the muscles of the articulatory apparatus (most often the tongue) occurs. Selective cortical paresis of individual muscles of the tongue leads to a limitation in the volume of the most subtle isolated movements: upward movement of the tip of the tongue. With this option, the pronunciation of front-lingual sounds is impaired.

To diagnose cortical dysarthria, a subtle neurolinguistic analysis is required to determine which of the anterior lingual sounds are affected in each specific case and what is the mechanism of their impairment.

In the first variant of cortical dysarthria, among the anterior lingual sounds, the pronunciation of the so-called kakuminal consonants, which are formed when the tip of the tongue is raised and slightly bent upward (w, g, p), is primarily impaired. In severe forms of dysarthria, they are absent, in milder forms they are replaced by other anterior lingual consonants, most often dorsal, when pronounced, the front part of the back of the tongue rises with a hump towards the palate (s, z, s, z, t, d, k).

Apical consonants, which are formed when the tip of the tongue approaches or closes with the upper teeth or alveoli (l), are also difficult to pronounce with cortical dysarthria.

With cortical dysarthria, the pronunciation of consonants according to the method of their formation may also be impaired: stops, fricatives and tremors. Most often - slotted (l, l).

Characterized by a selective increase in muscle tone, mainly in the muscles of the tip of the tongue, which further limits its subtle differentiated movements.

In milder cases, the pace and smoothness of these movements is disrupted, which manifests itself in the slow pronunciation of front-lingual sounds and syllables with these sounds.

The second variant of cortical dysarthria is associated with insufficiency of kinesthetic praxis, which is observed with unilateral lesions of the cortex of the dominant (usually left) hemisphere of the brain in the lower postcentral parts of the cortex.

In these cases, the pronunciation of consonant sounds, especially sibilants and affricates, suffers. Articulation disorders are variable and ambiguous. Finding the right articulatory pattern at the moment of speech slows down its pace and disrupts its smoothness.

The difficulty of feeling and reproducing certain articulatory patterns is noted. There is a lack of facial gnosis: the child finds it difficult to clearly localize a point touch to certain areas of the face, especially in the area of ​​the articulatory apparatus.

The third variant of cortical dysarthria is associated with a lack of dynamic kinetic praxis; this is observed with unilateral lesions of the cortex of the dominant hemisphere in the lower parts of the premotor areas of the cortex. With violations of kinetic praxis, it is difficult to pronounce complex affricates, which can break up into component parts, replacement of fricative sounds with stops (z - d), omissions of sounds in consonant clusters, sometimes with selective deafening of voiced stop consonants are observed. Speech is tense and slow.

Difficulties are noted when reproducing a series of sequential movements according to a task (by demonstration or by verbal instructions).

With the second and third variants of cortical dysarthria, automation of sounds is especially difficult.

Pseudobulbar dysarthria occurs with bilateral damage to the motor corticonuclear pathways running from the cerebral cortex to the nuclei of the cranial nerves of the trunk.

Pseudobulbar dysarthria is characterized by an increase in muscle tone in the articulatory muscles according to the type of spasticity - the spastic form of pseudobulbar dysarthria. Less commonly, against the background of limited range of voluntary movements, a slight increase in muscle tone in individual muscle groups or a decrease in muscle tone is observed - a paretic form of pseudobulbar dysarthria. In both forms, there is a limitation of active movements of the muscles of the articulatory apparatus, in severe cases - almost complete absence.

In the absence or insufficiency of voluntary movements, preservation of reflex automatic movements, strengthening of the pharyngeal and palatal reflexes, and also, in some cases, preservation of reflexes of oral automatism are noted. There are synkinesis. In pseudobulbar dysarthria, the tongue is tense, pulled back, its back is rounded and covers the entrance to the pharynx, the tip of the tongue is not pronounced. Voluntary movements of the tongue are limited, the child can usually stick his tongue out of the mouth, but the amplitude of this movement is limited, he has difficulty keeping his tongue stuck out in the midline; the tongue deviates to the side or falls on the lower lip, curving towards the chin.

The lateral movements of the protruding tongue are characterized by small amplitude, slow pace, diffuse movement of its entire mass; the tip remains passive and usually tense during all its movements.

Particularly difficult with pseudobulbar dysarthria is the upward movement of the protruding tongue with its tip curled towards the nose. When performing the movement, an increase in muscle tone, passivity of the tip of the tongue, and exhaustion of the movement are visible.

In all cases, with pseudobulbar dysarthria, the most complex and differentiated voluntary articulatory movements are disrupted first. Involuntary, reflex movements are usually preserved. For example, when voluntary movements of the tongue are limited, the child licks his lips while eating; finding it difficult to pronounce ringing sounds, the child makes them while crying, he coughs loudly, sneezes, laughs.

With paretic pseudobulbar dysarthria, the pronunciation of closed labial sounds that require sufficient muscle effort, especially bilabial (p, b, m) lingual-alveolar sounds, suffers, as well as often a number of vowel sounds, especially those that require lifting the back of the tongue upward (i, s, y). There is a nasal tone to the voice. The soft palate sags, its mobility when pronouncing sounds is limited.

Speech in the paretic form of pseudobulbar dysarthria is slow, aphonic, fading, poorly modulated, salivation, hypomimia and facial amyia are pronounced. Often there is a combination of spastic and paretic forms, i.e. the presence of spastic-paretic syndrome.

Bulbar dysarthria is a symptom complex of speech motor disorders that develop as a result of damage to the nuclei, roots or peripheral parts of the VII, IX, X and XII cranial nerves. With bulbar dysarthria, peripheral paresis of the speech muscles occurs. In pediatric practice, unilateral selective lesions of the facial nerve in viral diseases or inflammation of the middle ear are of greatest importance. In these cases, flaccid paralysis of the muscles of the lips and one cheek develops, which leads to disturbances and unclear articulation of labial sounds. With bilateral lesions, sound pronunciation disturbances are most pronounced. The pronunciation of all labial sounds is grossly distorted as they approach a single voiceless fricative labial sound. All stop consonants also approach fricatives, and the front lingual ones - to a single dull flat fricative sound, voiced consonants are deafened. These pronunciation disorders are accompanied by nasalization.

The distinction between bulbar dysarthria and paretic pseudobulbar is carried out mainly according to the following criteria:

• the nature of paresis or paralysis of the speech muscles (for bulbar - peripheral, for pseudobulbar - central);

• the nature of the speech motor disorder (with bulbar, voluntary and involuntary movements are impaired, with pseudobulbar - predominantly voluntary);

• the nature of the damage to articulatory motor skills (with bulbar dysarthria - diffuse, with pseudobulbar - selective with a violation of fine differentiated articulatory movements);

• specificity of sound pronunciation disorders (with bulbar dysarthria, the articulation of vowels approaches a neutral sound, with pseudobulbar dysarthria, it is pushed back; with bulbar dysarthria, vowels and voiced consonants are deafened; with pseudobulbar dysarthria, along with deafening of consonants, their voicing is observed);

• with pseudobulbar dysarthria, even with the predominance of the paretic variant, elements of spasticity are noted in certain muscle groups.

Extrapyramidal dysarthria. The extrapyramidal system automatically creates that background of pre-readiness, against which fast, accurate and differentiated movements are possible. It is important in the regulation of muscle tone, sequence, strength and motority of muscle contractions, and ensures automated, emotionally expressive performance of motor acts.

Violations of sound pronunciation with extrapyramidal dysarthria are determined by:

• changes in muscle tone in the speech muscles;

• the presence of violent movements (hyperkinesis);

• disorders of propriceptive afferentation from speech muscles;

• disorders of emotional-motor innervation. The range of movements in the muscles of the articulatory apparatus with extrapyramidal dysarthria, in contrast to pseudobulbar dysarthria, may be sufficient. The child experiences particular difficulties in maintaining and feeling articulatory posture, which is associated with constantly changing muscle tone and violent movements. Therefore, with extrapyramidal dysarthria, kinesthetic dyspraxia is often observed. In a calm state, slight fluctuations in muscle tone (dystonia) or some decrease in muscle tone (hypotonia) may be observed in the speech muscles; when attempting to speak in a state of excitement, emotional stress, sharp increases in muscle tone and violent movements are observed. The tongue gathers into a ball, is pulled towards the root, and sharply tenses. An increase in tone in the muscles of the vocal apparatus and in the respiratory muscles eliminates the voluntary activation of the voice, and the child cannot utter a single sound.

With less pronounced violations of muscle tone, speech is blurred, slurred, the voice has a nasal tint, the prosodic side of speech, its intonation-melodic structure, and tempo are sharply impaired. Emotional nuances in speech are not expressed, speech is monotonous, monotonous, unmodulated. There is a fading of the voice, turning into an unclear muttering.

A feature of extrapyramidal dysarthria is the absence of stable and uniform disturbances in sound pronunciation, as well as the great difficulty in automating sounds.

Extrapyramidal dysarthria is often combined with hearing impairment such as sensorineural hearing loss, with hearing for high tones primarily affected.

Cerebellar dysarthria. With this form of dysarthria, damage occurs to the cerebellum and its connections with other parts of the central nervous system, as well as the fronto-cerebellar pathways.

Speech with cerebellar dysarthria is slow, jerky, scanned, with impaired modulation of stress, and attenuation of the voice towards the end of the phrase. There is a decreased tone in the muscles of the tongue and lips, the tongue is thin, spread out in the oral cavity, its mobility is limited, the pace of movements is slow, there is difficulty in maintaining articulatory patterns and weakness of their sensations, the soft palate sags, chewing is weakened, and facial expressions are sluggish. The movements of the tongue are inaccurate, with manifestations of hyper- or hypometria (excessive or insufficient range of motion). With more subtle, targeted movements, a fine tremor of the tongue is noted. Nasalization of most sounds is pronounced.

Differential diagnosis of dysarthria is carried out in two directions: distinguishing dysarthria from dyslalia and from alalia.

The distinction from dyslalia is made on the basis of identifying three leading syndromes (syndromes of articulatory, respiratory and vocal disorders), the presence of not only disturbances in sound pronunciation, but also disorders of the prosodic side of speech, specific disturbances in sound pronunciation with difficulty in automating most sounds, as well as taking into account the data of a neurological examination ( the presence of signs of organic damage to the central nervous system) and features of the anamnesis (indications of the presence of perinatal pathology, features of pre-speech development, screaming, vocal reactions, sucking, swallowing, chewing, etc.).

The distinction from alalia is made on the basis of the absence of primary violations of language operations, which is manifested in the peculiarities of the development of the lexical and grammatical aspects of speech.

SYSTEM OF CORRECTIONAL PEDAGOGICAL WORK

The close relationship between the development of speech, sensory functions, motor skills and intelligence determines the need for correction of speech disorders in dysarthria in children in combination with stimulation of the development of all its aspects, sensory and mental functions, thereby realizing the formation of speech as an integral mental activity.

The system of speech therapy treatment for dysarthria is complex: correction of sound pronunciation is combined with the formation of sound analysis and synthesis, development of the lexical and grammatical aspect of speech and coherent utterance. The specificity of the work is the combination with differentiated articulation massage and gymnastics, speech therapy rhythms, and in some cases with general physical therapy, physiotherapy and drug treatment.

The success of speech therapy classes largely depends on their early start and systematic implementation.

Work on sound pronunciation is based on the following provisions:

1. Dependence on the form of dysarthria, the level of speech development and the age of the child.

2. Development of speech communication. The formation of sound pronunciation should be aimed at the development of communication, school and social adaptation of the child.

3. Development of motivation, desire to overcome existing disorders, development of self-awareness, self-affirmation, self-regulation and control, self-esteem and self-confidence.

4. Development of differentiated auditory perception and sound analysis.

5. Strengthening the perception of articulatory patterns and movements through the development of visual-kinesthetic sensations.

6. Step by step. They start with those sounds whose articulation is more intact in the child. Sometimes sounds are chosen on the basis of simpler motor coordination, but always taking into account the structure of the articulatory defect as a whole; first of all, they work on the sounds of early ontogenesis.

7. In case of severe disorders, when speech is completely incomprehensible to others, work begins with isolated sounds and syllables. If the child’s speech is relatively clear and he can pronounce defective sounds correctly in individual words, work begins with these “key” words. In all cases, automation of sounds is necessary in all contexts and in various speech situations.

8. In children with damage to the central nervous system, it is important to prevent severe disorders of sound pronunciation through systematic speech therapy work in the pre-speech period.

Speech therapy work for dysarthria is carried out in stages.

The first stage, preparatory - its main goals: preparation of the articulatory apparatus for the formation of articulatory patterns, in a young child - nurturing the need for verbal communication, development and clarification of passive vocabulary, correction of breathing and voice.

An important task at this stage is the development of sensory functions, especially auditory perception and sound analysis, as well as the perception and reproduction of rhythm.

Methods and techniques of work are differentiated depending on the level of speech development. In the absence of verbal means of communication, initial vocal reactions are stimulated in the child and induce onomatopoeia, which is given a character of communicative significance.

Speech therapy work is carried out against the background of medication, physiotherapy, physical therapy and massage.

The second stage is the formation of primary communicative pronunciation skills. Its main goal: the development of speech communication and sound analysis. Work is being carried out to correct articulation disorders: in case of spasticity - relaxation of the muscles of the articulatory apparatus, development of control over the position of the mouth, development of articulatory movements, development of the voice; correction of speech breathing; development of sensations of articulatory movements and articulatory praxis.

Work on relaxing the muscles of the articulatory apparatus begins with general muscle relaxation, relaxation of the neck, chest muscles, and arm muscles. Then a relaxing facial muscle massage is performed. Movements begin from the middle of the forehead towards the temples. They are performed with light stroking, uniform movements with the fingertips at a slow pace.

A relaxing massage is carried out in doses, applying only to those areas of the face where there is an increase in muscle tone, while a tonic, strengthening massage is used in flabby and weakened muscle groups.

The second direction of a relaxing facial massage is the movement from the eyebrows to the scalp. Movements are carried out evenly with both hands on both sides.

The third direction of movement is downward from the forehead line, through the cheeks to the muscles of the neck and shoulder.

Then they begin to relax the lip muscles. The speech therapist places his index fingers on a point located between the middle of the upper lip and the corner of the mouth on both sides. The movements go towards the midline, so that the upper lip is gathered into a vertical fold. The same movement is done with the lower lip, then with both lips together.

In the following exercise, the speech therapist's index fingers are placed in the same position, but the movements go up the upper lip, exposing the upper gums, and down the lower lip, exposing the lower gums.

Then the speech therapist's index fingers are placed at the corners of the mouth and the lips are stretched (as if smiling). With a reverse movement, the lips return to their original position with the formation of wrinkles.

These exercises are performed in different positions of the mouth: the mouth is closed, slightly open, half-open, wide open.

After relaxation, and in case of low tone, after a firming massage of the lips, they are trained in passive-active movements. The child is taught to grasp and hold lollipops and sticks of various diameters with his lips, and is taught to drink through a straw.

After general muscle relaxation and the exercises described above, begin training the muscles of the tongue. When relaxing them, it is important to consider that they are closely connected to the muscles of the lower jaw. Therefore, the downward movement of the spastically raised tongue in the oral cavity is most easily achieved with a simultaneous downward movement of the lower jaw (mouth opening). For school-age children, similar exercises are offered in the form of auto-training: “I am calm, completely relaxed, my tongue lies calmly in my mouth. I slowly lower it down when my lower jaw drops.”

If these techniques are not enough, then it is useful to place a piece of sterile gauze or a sterile stopper on the tip of the tongue. The resulting tactile sensation helps the child understand that something is interfering with the free movements of the tongue, i.e., to feel a state of spasticity. After this, the speech therapist uses a spatula or tongue depressor to apply light horizontal pressure.

The next technique is light, smooth swaying movements of the tongue to the sides. The speech therapist carefully grabs the tongue with a piece of gauze and smoothly rhythmically moves it to the sides. Gradually, the passive assistance of the speech therapist decreases, and the child begins to perform these exercises himself. The massage is performed by a specialist (physical therapy), but its elements are used by a speech therapist and parents under the mandatory supervision of a doctor, in compliance with the necessary hygienic rules.

Developing control over mouth position. Lack of control over mouth position in children with dysarthria significantly complicates the development of voluntary articulatory movements. Usually the child’s mouth is slightly open and drooling is pronounced.

The first stage of work is exercises for the lips, helping to relax them and enhance tactile sensations in combination with passive closing of the child’s mouth. Attention is fixed on the sensation of a closed mouth, the child sees this position in the mirror.

At the second stage, the mouth is closed in a passive-active way. At first, it is easier for a child to close his mouth when his head is tilted, and easier to open when his head is slightly tilted back. At the initial stages of work, these lightweight techniques are used. The transition from passive mouth opening movements to active ones becomes possible through reflex yawning.

At the third stage, active opening and closing of the mouth is trained according to verbal instructions: “Open your mouth wide,” “Pull your lips forward,” “Gather your lips into a tube and return them to the starting position.”

Various tasks are offered to imitate the position of the mouth presented in the pictures. Gradually, the exercises become somewhat more complicated: the child is asked to blow through relaxed lips and make vibration movements.

Conclusions and problems

The structure of the defect in dysarthria includes a violation of the sound pronunciation and prosodic aspects of speech, caused by organic damage to the speech motor mechanisms of the central nervous system. Sound pronunciation disorders in dysarthria depend on the severity and nature of the lesion.

The main clinical signs of dysarthria are:

• violations of muscle tone in the speech muscles;

• limited possibility of voluntary articulatory movements due to paralysis and paresis of the muscles of the articulatory apparatus;

• voice and breathing disorders. The main signs of pseudobulbar dysarthria are: increased tone in the articulatory muscles, limited movements of the lips, tongue, soft palate, increased salivation, breathing and voice disorders. Children chew, swallow poorly, and choke when eating. Speech is blurred, incomprehensible, intonation-inexpressive, monotonous, the voice is dull, with a nasal tint. Dysarthria is often combined with underdevelopment of other components of the speech system (phonemic hearing, lexico-grammatical aspects of speech). Depending on the severity of these manifestations, it is extremely important for speech therapy practice to identify several groups of children with dysarthria: with phonetic disorders; phonetic-phonemic underdevelopment; general underdevelopment of speech (the level of speech development is indicated). For purely phonetic (anthropophonic) disorders, the main task is to correct sound pronunciation. When dysarthria is combined with speech underdevelopment, a comprehensive system of speech therapy is carried out, including phonetic work, the development of phonemic hearing, work on vocabulary, grammatical structure, as well as special measures aimed at preventing or correcting disorders of written speech.

Important problems in the modern study of dysarthria are:

• neurolinguistic study of various forms of dysarthria, taking into account the location of brain damage;

• development of methods for early neurological and speech therapy diagnosis of minimal manifestations of dysarthria in children;

• improving the methods of speech therapy work in the pre-speech period and in the first years of life with children with perinatal brain damage and with children at risk;

• improvement of methods of speech therapy work, taking into account the form of dysarthria;

• strengthening the relationship in the work of a neurologist and speech therapist;

• expansion of the aspect of the psycholinguistic study of dysarthria from the point of view of the process of speech generation and disruption of the implementation of the motor program due to the immaturity of the operations of the external design of the utterance. Studying the relationship between vocal, tempo-rhythmic, articulatory-phonetic and prosodic disorders with semantic disorders in various forms of dysarthria will increase the effectiveness of speech therapy.

Correction of sound pronunciation

The peculiarity of voice correction for dysarthria is that it is a complex and lengthy process. From a physiological point of view, teaching a person to pronounce sounds is tantamount to creating a new conditioned reflex. If for dyslalia the method of staging by imitation is very effective, then for dysarthria speech therapists more often use a mixed method using mechanical assistance, speech therapy probes and the method of passive formation of articulatory structure, when the speech therapist, with the help of hands, special devices and probes, gives the patient’s tongue and lips the desired position . You can use auxiliary objects: a teaspoon, tubes, sticks of various diameters.

Voice correction technology for dysarthria is a long-term, painstaking and systematic work on the development of articulatory motor skills and automation of delivered sounds. Articulatory gymnastics and speech therapy massage do not stop at the stage of voice development, but are continued and combined. Speech therapists use individual techniques for producing sounds, analyzing the causes and nature of disorders.

Correction of the pronunciation aspect of speech

The pronunciation side of speech includes sound pronunciation and prosody (intonation, melody, pause, stress, tempo, rhythm and timbre). The functioning of the pronunciation side of speech is closely related to articulatory motor skills and the phonemic side of speech. Pronunciation of sounds is the phonetic design of speech and at the same time a complex of speech motor skills by which it is determined.

Corrective work is based on the following principles:

1. Connections of speech with other aspects of mental development. To implement it, correctional influence is carried out not only on speech activity, but also on non-speech processes, the patient’s personality as a whole;
2. Systematic approach. The pronunciation side is considered as a system that includes a number of components. Corrective work is aimed at their development (development of articulatory motor skills, sound pronunciation, phonemic perception, prosody);
3. The development principle involves analyzing the process of the occurrence of a defect. The immediate result of impaired sound pronunciation in patients with dysarthria is limited mobility of the speech organs. Difficulties in articulation cause pronunciation deficiencies, which can be expressed to varying degrees. One manifestation may be a consequence or cause of another. Corrective work is directed not only at the consequence of the violation - defects in sound pronunciation, but also at their root cause - violations of articulatory motor skills.

Correctional speech therapy work is carried out using various methods: practical, visual, verbal. Practical methods include imitative-performing, constructive and creative exercises, games and modeling. Visually - observation, examination of profiles, diagrams, showing a sample task and method of action. The main verbal methods are conversation, reading, story.