The Coordination therapy. Summary
The coordination-therapy (CTh) was developed by Elfriede Öcker for treatment as a holistic approach to the treatment of voice disorders. Öcker was the director of an institute for speech and language therapists in Linz (Austria), and has worked together with Professor Coblenzer, who was teaching at the Academy of Dramatic Art in Vienna. Therefore, a lot of Coblenzer’s ideas were assimilated in the CTh. In fact, Öcker developed an approach, which may be used to implement the exercises of Coblenzer after creating a solid basis. Of course, treatment can only be started after organic disease has been ruled out by medical diagnosis. If necessary, assistance from other disciplines must be evoked.
The CTh has the potential of providing help to all non-organic problems with phonation, articulation and respiration, and, after medical intervention, also to organic problems in this scope. Although originally developed particularly for voice disorders, the CTh can, due to its very basic and holistic approach, contribute to the treatment of many other disorders. In this respect, we can think of disorders such as stuttering, hyperventilation, dysphagia, globus sensation, facialis parese, TMD, dysarthry or aphasia. It is a comprehensive therapy, and the therapist has to select from its possibilities, thus adjusting to the problems of each individual patient. Application of the therapy gives good results and relapses are rare.
Speaking as a way to express oneself needs the dedication of mind and body.
In the CTh the therapist first observes the whole body in rest, as well as while moving and speaking, in order to detect all aspects inhibiting an optimal phonation. The purpose of this first step is creating a solid basis for respiration and phonation practises.
In Öcker’s opinion, every design in nature has a purpose. Therefore, bodily functions can only accomplish their special tasks in an efficient way, thus interacting optimally with all the other bodily functions and systems, but allowed to proceed in their own way. So, we have to study the way nature is functioning. In case of disorders, we must try to go back to natural functioning by eliminating all forcing mechanisms. Our purpose must not be changing the natural design, but understanding, and going back to it.
Secondly, the therapist pays attention to psychosocial aspects playing a role in speaking. It is generally accepted that voice disorders are partly psychogenic, resulting from psychosocial stress. For instance, speaking in a higher voice in alarming or exciting situations requires several forcing mechanisms such as tensing the throat muscles and breathing in a fast shallow pattern. This is known as verbal emotional expression. If a patient has a lot of problems, tensed laryngeal muscles in combination with respiratory dysfunction can become chronic, and cause implications, not only for his voice but also for his well-being.
A. Respiration posture and movement
Anatomically, there are specific structural divisions which, when hypertonic or imbalanced in their tonicity, act as areas of functional restriction. As a result, effects of head position on the dynamics of the pharynx and the upper oesophageal sphincter will next influence swallowing, breathing, articulation and phonation. Aberrations of head posture are too much extension, too much flexion or wryness of the neck by dystonus of the m. sternocleidomastoideus.
Also lordosis, often seen together with a wrong head position, will inhibit the slight action of the lumbar region going with a good deep diaphragmatically inspiration. The spinal column is relatively rigid, except for the cervical and lumbar vertebrae. Any bending of the body almost entirely takes place within the five large lumbar vertebrae, and many muscles employed for the support of the body are concentrated in this critical area. The majority of the muscles in the lumbar area are employed in respiration and in that way involved in speech.
A particular abnormal hypertonia of the body is often a common secondary finding in a vast number of conditions. Frequently, after the primary condition has been cleared, the forcing mechanisms remain. For instance, after long-time abnormal diaphragm movements in case of lasting bellyache, the often asymmetrical tension patterns persist in spite of successful medical intervention. Therefore, it is always important for the therapist to initiate therapy by observing posture and movement in connection with breathing. If required, all forcing mechanisms influencing respiration, posture and movement, as well separate as in their mutual interactions, are to be eliminated. Only after adequate treatment, it is possible to practice diaphragmatic breathing pattern in supine, sitting and upright position, and to make isolated movements in this postures. When speaking of isolated movements, Öcker means movements executed without activating any compensating musculature. For instance, lifting an arm without simultaneously lifting the shoulder is one of the exercises in this stage of the CTh. When a patient is upholding his shoulders, execution of an isolated arm movement is impossible.
Also, every movement, active as well passive, is accompanied by an inspiration, or every increase of muscle tension induces an inspiration. Only with powerful movements the start is made on expiration. For instance with playing tennis, we inhale during moving the racket backwards and exhale together with the forward movement in order to play the ball. This applies also for every sensible stimulus. For instance, looking at a glance to a person or an object induces a tiny inspiration. Patients with voice disorders often hold their breath at the start of a movement, thus disturbing their breathing patterns.
Altogether, a good deep diaphragmatic respiration pattern is only possible after accomplishing optimal posture and mobility and a good interaction between the three functions. When this target is reached, breathing will influence several bodily functions and systems in a positive way, such as heart function, blood circulation and digestion. Also, it will stimulate the quality of the voice in every respect.
For the elimination of forcing mechanisms and the correction of posture, movement and breathing pattern, CTh provides several possibilities. The therapist starts with massage of the tensed hyoid- and extrinsic larynx muscles often associated with voice disorders. The larynx is moving up- and downward during swallowing, yawning and articulation. To achieve these movements, its extrinsic muscles must have the right tonus. If these muscles are too tensed, mobility will be restricted and a fixated raised position of the larynx will be induced. In that case, the respiration-, swallow- and articulation functions will be negatively influenced, phonation will be affected by the reduction of the resonance spaces, and globus sensation can appear. Thus relaxation of these muscles will not only stimulate an optimal mobility of the larynx, but also facilitate a good low rest position of the larynx and hyoid as well as an optimal rest position of the tongue. This is the required starting point for optimal articulation and phonation.
Too much contraction of the muscles of the sternum area and the diaphragm leads to irregular, thoracic breathing. By elimination of eventual hypertonia by massage of the sternum and the diaphragm, a slow deep breathing pattern will be facilitated. Considering the directional orientation especially of the muscle fibres of the diaphragm, it becomes apparent how various restrictions and distortions of tissue motion can occur. These circumstances form an obstacle for normal diaphragm mobility, and thus inhibit an optimal breathing pattern in rest, moving and speaking.
After this regular breathing exercises are executed.
To improve the patient’s posture, alternated movements of the extremities (stretching and bending) are executed by the therapist. Therapists can learn these exercises in our workshops. They are very comforting to the patient.
B. Feeding function
As mentioned above, hypertonia of hyoid muscles hampers the resting position and mobility of larynx, hyoid and tongue, and will ongoing stimulate dystonus of the muscles of palate, pharynx, cheeks, lips and chin. Consider that at least seven muscles are active in this area to stabilize the position of the hyoid bone. The laryngeal muscles are in the first place involved in respiration, mastication and swallowing and secondary in articulation and phonation. An imbalance in this area can primarily stimulate disorders such as globus sensation, aspiration, reflux, heartburn and TMD, and only secondary articulation and voice problems.
Massage of palate, lips, cheeks, chin, region of the temporomandibular joint, cheek-bones and the m. temporalis (behind the ear) are executed by the therapist.
Next follows practise of yawning with accent on a nice downward and upward movement of larynx and hyoid and complete diaphragmatic respiration Aim of this exercise is obtaining optimal mobility of larynx and hyoid in up- and downward direction. With yawning the larynx reaches his lowest position. Optimal yawning movement is very comforting as it goes with a deep diaphragmatically inspiration, followed by long expiration. In this way a lot of air enters and leaves the lungs.
In case of raised rest position of larynx and hyoid and the ongoing proposition of the tongue, it is possible that the mandible is shoved a bit in anterior direction. This leads to articulation dysfunctions as sigmatismus interdentalis and to a restriction of the resonance spaces. Also the jaw movements are not performed in the right way and can evoke TMD. Therefore, control and eventually correction of the biting habits for substantial food (such as a cookie) will be necessary.
Also practising the swallow movement with emphasis on the little expiration after the swallow is done. At the end of the chewing phase the larynx is raised and moves under the tongue base in order to protect the airway. This is the onset for the swallow. The lips are closed and the tongue will be elevated from anterior to posterior to transport the bolus through the oral cave. The fact that the posterior part of the tongue is touching the soft palate triggers the palate to close the nasopharynx in a reflex. Then the bolus is transported through the pharyngeal cave by the contraction of the mm pharynges constrictor and will reach the oesophagus by the opening of the upper sphincter. This is followed by a little expiration which initiates the descent of larynx and hyoid to their normal low rest position. Often this little expiration is omitted, which can cause not only symptoms of globus, but will also reduce the resonance spaces and so influence phonation function.
Control and eventually correction of the way of drinking fluids is the next step of the therapy. Correctly taking a sip means pulling the upper lip, touching the liquid by the inside of the upper lip in order to control its temperature, correctly closing of the lips, transporting the liquid to the oral cave in posterior way, and swallowing. Often, the upper lip muscles are too tensed or too relaxed. This is accompanied by inhibited elevation of the soft palate, and will thus stimulate leakage of liquid through the nose, and influence phonation by the manifestation of increased nasalization. When pulling up the upper lip together with an inspiration you can feel the movement of the soft palate. Besides distonus of the lip muscles will influence the articulation of the labial vocals.
Massage of the upper lip, practise of pulling up the upper lip simultaneously with an inspiration and drinking of a sip of water in the right way will eliminate possible dysfunctions in this area.
In the scope of the treatment of voice disorders, it is important to realise that the way of producing a vowel or a consonant influences the respiration patterns in speaking.
With the consonants the place of production is important. If e.g. the tongue is moving in a proposition while producing the /S/, the larynx and hyoid will be lifted too much as tongue, larynx and hyoid are connected with each other. This results not only in aberration of the articulation of the /S/ but also in inhibition of the resonating cavities by the exaggerated uplifting of larynx and hyoid.
Secondly, the production strength must be adjusted. For instance, too little or too much lip pressure in combination with muscle tension with the production of the /P/, not only means dystonus of the lip and cheek muscles, but also irregulation of subglottic air pressure and expiration air flow. Subsequently, a good and economic inhalation is not possible.
So it is obvious that place and strength of production can influence breathing patterns as well as resonance spaces, and, as a result, phonation.
In the therapy model the massage of the throat- and orofacial muscles form the base. Only when eutonus in this scope is accomplished the real articulation training can start. This is done by several muscular-kinesthetical practises partly executed by the therapist and partly done by the patient himself.
In this way the exact production of the consonants (just place and just strength) and the vowels (just lip parting, tongue position) can be reached.
D. Respiration regulation in speaking and moving
Coupling of respiration with moving is already mentioned. Start of each movement normally goes with an inhalation.
Coupling of speaking with respiration is another matter we have to observe. At the moment we loose the articulation tension (which means relaxation of muscles of tongue, velum, lips and/or cheeks), the diaphragm can become active (which means inspiration). Therefore, loosing the articulation tension forms the onset for an inspiration. At the moment that the diaphragm looses its tension at the start of a following expiration, the articulation tension can increase again or in other words, articulation can take place. This process can be disturbed in several ways. The consequences of wrong production of consonants and vowels are already discussed. Another phenomenon is taking a deep breath at the onset of speaking. Here the inspiration air flow is too big, and hampers sequentially the process of expiration flow and phonation. Also speaking too long on one breath or too loud disturb the process. Subglottic pressure can be too strong, expiration flow will either be increased or decreased.
As a result of this wrong techniques, the loosening of articulation tension is not optimal, and initiating the right inspiration movement of the diaphragm will become impossible. Sequentially the correct amount of air for saying the word (or words) we intend to speak can’t be required etc..
(Mind here that hyperventilation is often caused by dysfunction of the respiration in speaking.)
By training the producing of the different vowels and consonants right way and with the right strength, the airstreams coming from the larynx will be modified in an optimal way, and thus stimulate the quality of respiration and voice production. After this, training of communication skills as verbal emotional expression is important. This is done with emphasis on posture, gesture, mimic and accent.
After lying a stable foundation by the above described massages and exercises, all sorts of vocal exercises can be performed to improve the quality of the phonation. Öcker has not developed a special model, but uses, for instance the traditional voice exercises of Coblenzer, Pahn and Smith.
As mentioned before inhibition of the resonating cavities can arise as the result of wrong posture of neck and shoulders or a too uplifted larynx. Therefore, resonance exercises are done with emphatic attention on posture and movement in order to reach optimal size of the resonating cavities (laryngopharynx, oral and nasal cavities and head sinuses) that form the vocal tract. The shape of these vocal cavities can be changed in several ways along with positional changes of the articulators, velum, epiglottis and pharyngeal walls. Based on the action previously produced at the level of the vocal folds this process modifies the voice.
Voice registers are in fact the different muscular systems that are used to reach chest and head resonance or phonation in lower and higher frequencies. To get fluent change over from one register to another gliding exercises on vowels are performed.
To get control on subglottic air pressure, speaking exercises are done with differing pitch and volume.
Complete occlusion of the vocal cords, needed in speaking is stimulated by producing a tiny click-sound (vocal fry) followed by a very small expiration. In Germany it is called ‘das Ventiltönchen nach Rudolf Schilling’.
Optimal onset in the producing of vowels is reached by performing the articulation position of the relevant vowel just before the phonation. Often the prevocalic action is too strong, what means that the vocal cords are opened with too much strength. Exhalation air flow is in that case disturbed.
Accents influence vivacity of human speech and emotional expression but they have also impact on respiration-, articulation- and phonation. Rhythmic accents influence speech respiration by regulating the pattern of inspiration and expiration during speaking, dynamic accents affect respiration by evoking alterations in subglottic pressure and expiration air flow, and emotional accents bring the emotions in the human voice by alterations in pitch.
Optimal use of accents can be best accomplished by the training of all sorts of communicative skills. We use here mostly the exercises of Coblenzer.
G. Integration of learned skills in day life
Implications of psychosocial and organizational factors at work play a role. Therefore, job stress can cause many symptoms in breathing, swallowing and speaking. During therapy the patients are informed about the physiology of the voice and of the connections and interactions between vocal dysfunction and psychosocial factors. Getting clear insight will help the patient in his attempts to deal with stressful events.
Also, implantation of all newly learned skills in daily life must be the goal. Incorrect application of executing tasks in the household, in office or with sporting will diminish the benefits of the treatment and can lead to relapses.
Therefore, this stage of treatment involves special training, focused on profession and hobbies of a patient. The therapist must be well posted in the patient’s day life, enabling special advices on this subject.
Getting familiar with the mistakes that can me made is usually sufficient to prevent relapses, and full integration of the learned skills can be reached by the patient.
Speaking is a very complex function. Appropriate work-up includes a careful history, thorough physical examination and eventual intervention, and of course optimal dedication of the speech therapist.
The extensive seizing of the CTh forms an excellent addition in the approach of voice disorders. Knowledge of the numerous interactions between the respiration-, feeding- and speaking functions, and the arising consequences of every irregulaty of as well separate functions as of their connections, enables the therapist to give insight to the patient in his specific problems and to create an optimal therapy plan. By establishing a stable base and by implementation of all techniques in day life the quality of the phonation will improve, and relapses can be reduced. In many cases, patients reported several positive effects on their well being.
Making a good therapy plan for each patient by selecting only those aspects of the CTh which are needed to deal with his particularly irregularities, enables an effective treatment for everyone.
Obviously, describing massages and particular exercises do not qualify every therapist to use these aspects of the CTh. For this reason several workshops are organized, as well in the Netherlands as in other countries.
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