Exercises for People with Severe Communication Impairment

---

Preparation for Communication Device Use

People with speech problems may have to supplement or replace their speech with augmentative communication devices such as alphabet boards, keyboards, or switches. These methods have their own physical requirements, and are often difficult for people with associated physical handicaps (people with Down Syndrome, for example, often have low muscle tone). These development activities are intended to help them improve their hand skills.

Shoulder Girdle Activities

The muscles of the shoulder, upper body and arms must be strong to permit good hand function. The muscles of the upper body act as stabilizers so that the hands can perform tasks accurately and effectively. If these muscles are weak a person will find it hard to sustain an activity such as using a keyboard as he will be unable to maintain his hands in the correct position.

Rich has Down Syndrome and low muscle tone. Because of his low muscle tone he hasn’t played much sport. Correspondingly, his low muscle tone was complicated by low muscle strength — he hadn’t been using his arm and shoulder muscles as much as other children, so they were weaker. When his family realised the problem they started going to the local pool regularly, where Rich swam laps. As well, Rich’s father put up a basketball hoop on the garage and Rich spent half-an-hour each evening happily shooting baskets when he came home from school. Not only did Rich’s typing improve; he developed skills which meant he was able to participate successfully in group sporting activities at his school.

An important factor in developing and maintaining muscle strength is participation — participation in all those activities of daily life that are routine for children and adults without disabilities, activities such as carrying shopping, housework, and gardening, as well as swimming and ball games. Following is a short list of activities that will strengthen the arm and shoulder muscle groups. — obviously there are many others.

* volleyball

* basketball/netball – shooting goals

* swimming

* tug-of-war

* washing the floor on hands and knees with a cloth

* using a squeeze mop

* using a broom, especially outdoors

* raking leaves

* washing windows and mirrors, especially above shoulder height

* putting things on high shelves

* scrubbing the bath or the shower recess

* digging in the garden

* doing pushups

* hanging out the washing or bringing it in (winding the line up high)

* painting large surfaces such as fences or walls

* climbing – gym ladders, monkey bars, climbing frames, or ropes

* squeezing oranges or lemons

* balloon volley ball, ‘keeping off’

* cleaning the cobwebs from the ceiling

* changing light globes

* playing ‘push me, pull me’, or ‘oranges and lemons’, or Twister.

* rowing (or using rowing machines)

* weight lifting (or wearing wrist weights while doing other activities)

*upper-body aerobics

* mowing the lawn with a hand mower

* pushing prams or shopping trolleys

* fruit picking

N.B.If the person has a history of arthritis, fractures, contractures, dislocations or other painful hand or arm problems do consult a therapist before undertaking any activities.

People with motor-planning problems may need initial assistance in developing the movement patterns necessary to succeed at specific activities. For example, Don positioned himself behind Tom and placed his hands over Tom’s so he could help Tom catch and throw a basketball. He reduced his input as Tom’s skills improved.

Improving Finger-Pointing Skills

Despite what our mothers told us, it’s not always rude to point. Pointing is a very useful skill. It is especially important for people who have severe speech impairments,as it offers a powerful means of augmenting their speech. An infant may point at the toy they want, an older child may point at symbols on a communication board, a teenager may type.

For effective finger pointing you need to be able to extend one finger, usually the index finger, of the preferred hand while keeping back the other fingers. You also need to have the eye/hand co-ordination to line up the finger and the target.

Problems

The main problems we have seen with finger-pointing and some remedies are:

Difficulty isolating one finger – that is, difficulty extending one finger while keeping the others back.

The student should be encouraged to do exercises using only one finger. It may be necessary to hold the other fingers back at first until the isolation becomes habitual. Some children wear an old sock with a small hole cut in it pulled down over the dominant hand and held at the wrist with a tie, so that only the index finger can extend through the hole. This should be used only while using a communication aid or doing pointing exercises. If index finger isolation shows no improvement after a few weeks of exercises, seek further advice from an occupational therapist.

Weakness – that is, there is difficulty stiffening the index finger and applying pressure.

Preference should be given to finger exercises requiring pressure, and every effort made to ensure that the finger remains straight when pressing. Splints are used as a last resort in the rare instances where the exercises do not produce sufficient improvement. We do not encourage the early use of splints or the provision of finger support by facilitators because these strategies are unlikely to result in the strengthening of the finger muscles and therefore entail continued dependency on splinting or facilitation.

Wobble – that is, the finger moves from side to side, resulting in uncertainty as to the selection wanted or, if a keyboard is being used, producing typing errors.

As for weakness, preference should be given to exercises involving pressure. As well as the finger, the stability of the wrist should also be assessed. Often the problem with the finger is produced or made worse by lateral instability of the wrist. If this is the case, exercises to strengthen and balance the arm muscles will also be needed.

Poor eye-hand co-ordination – that is, pointing without looking or failing to keep the eyes on the target, resulting in incorrect selections.

Any activities involving selection from a set of items may be used for eye-hand co-ordination practice. Choose materials that are as interesting and age appropriate as possible – say Ladybird picture books and insert puzzles for a pre-schooler, Happy Families cards and jigsaws for a primary student,pop stars and footballers for a teenager. The activities are meant to be fun, not a test. The sole aim is to ensure that when students point they are looking at where they are pointing. It does not matter if the pointing is co-active at the start, as long as the students keep their eyes on the target.

Many individuals have more than one of these problems. Sometimes this means they need to do several kinds of activities to remedy all their difficulties, sometimes it is possible to find an activity that addresses more than one problem. For example, the Touch and Tell is a toy with bright picture overlays which speaks when the overlay is pressed. It requires firm pressure to operate it, so it can be used to address weakness and wobble problems as well as providing a good stimulus for eye-hand co-ordination training.

Some activities require more supervision than others. Care should be taken at the start of all activities to ensure that the movements are being performed correctly – it is unfortunately perfectly possible to operate a Touch and Tell with the whole fist without looking at all, but of course no improvement in finger pointing will result! Five or ten minutes a day of supervised exercises usually produces rapid improvement in index finger isolation and strength.

Sometimes caregivers and teachers feel that it is easier to give a student a splint or a pointer than do exercises to compensate for index finger isolation and weakness problems. While it is quicker initially, consider the time needed to make and hunt for pointers/splints in the future. If we can improve the students’ own hands, we are giving them skills they will have for the rest of their lives. We think it is possible to develop independent index finger pointing skills in almost all individuals with developmental disabilities who do not have severe cerebral palsy or hand deformities.

As students improve their pointing skills it is important to encourage increased independence. Students can be encouraged to point independently to desired foods, drinks or activities when appropriate. The support offered to students using facilitated communication should be reduced as their finger pointing improves. Students who can isolate their index fingers do not require their hands held, though they may still require wrist support to counteract other problems, such as tremor.

N.B.If the person has a history of arthritis, fractures, contractures, dislocations or other painful hand or arm problems do consult a therapist before undertaking any exercises.

Exercises and Activities

Poking holes in balls of clay,plasticine or playdough.
Poking holes in plastic wrap stretched over a bowl.
Pushing finger into a balloon.(watch out!).
Drawing with the tip of one finger in fingerpaint or shaving cream on table or mirror.
Using toys with push buttons or dials (e.g. toy phones).
"Educational"toys which require pressure to make a selection e.g. Touch and Tell, Play and Learn.
Pushing holes in soil to plant seeds.
Pointing to pictures or parts of pictures.
Pointing to pieces from insert board or jigsaw puzzle to show you what goes where.
Picture lotto, dominoes and card games where matching items can be indicated by pointing
Keyboard toys or musical instruments – again, played with only one finger.
Making collage pictures by pointing to item wanted and then to the place on the paper where it should be pasted.
Tracing patterns and shapes in wet sand.

Remember to make use of everyday situations (flushing the toilet, turning lights on and off, pressing pedestrian buttons, selecting a TV channel, operating a cassette player, dialing the phone, operating household equipment, etc.) to develop index finger skills. These not only develop pointing skills, they are motivating and necessary activities in their own right.

DEAL Communication Centre