Q: My 6-year-old male client keeps his lips in a perpetual smile that is interfering with intelligibility when he speaks. He appears to have low muscle tone. He also has great difficulty producing multisyllabic words. I am wondering where to begin?

Your client has lip retraction associated with mild dysarthria. How do I know he has dysarthria? Because he has speech distortion related to neuromuscular disturbance.  That is the very definition of dysarthria.

I have written the following about lip retraction and how to fix it.  This is from The Marshalla Guide to be published next year.  The inhibition techniques and a mirror are the most useful.

Excerpt From The Marshalla Guide

Some clients pull the lips back away from midline during speech in a pattern called lip retraction.  Lip retraction is caused by excessive tightness or contraction in one or more of the extrinsic lip muscles.  Lip retraction can have a neuromuscular basis or it can be the result of simple habit.  Lip retraction can occur in all 360 degrees around the lips, it can be limited to either the upper or lower lip, it can be limited to either the left or right side of the lips, or it can occur in only one quadrant.  Lip retraction disturbs oral resonance, it restricts lip movements for production of bi-labial and labial-dental consonants, and it impacts clarity of the vowels.

Inhibiting Unnecessary Lip and Cheek Movements

Sometimes unnecessary or incorrect lip or cheek movements must be prevented or inhibited… Inhibition of lip or cheek movements must be used in cases where a simple verbal instruction like “Don’t move your lips” or “Don’t puff up your cheeks” is insufficient.  In these cases, one can utilize very specific methods to teach the client to inhibit these excessive movements––

• Fingers:  The therapist’s fingers can be placed on a client’s lips or cheeks to hold them out of the way or in place while he produces any phoneme–– “Occasionally it may be necessary to inhibit action of the lips [or the cheeks] by pressing them gently against the teeth with the fingers” (Nemoy and Davis, 1937, p. 137).
• Tape:  A small strip of tape can be placed on either side of the lips or on the cheeks to signal a client that he is moving them unnecessarily.  Old-timers used regular household sticky tape and masking tape but today we have KinesioTape which is a new product that is safe enough to use on a baby’s skin.

Reducing Lip and Cheek Tension

The motor therapy known as neurodevelopmental treatment proposes that abnormal movement activity should be inhibited before more normal activity is stimulated.  Therefore tight lip and cheek muscles need to be relaxed before the lips are encouraged to move more, and tightness in the cheeks needs to be relaxed for good oral resonance.  The following methods can be employed to reduce tension in the lips and cheeks––

• Plucking:  Some old-time articulation therapists used plucking to reduce tension localized to the lips.  For example, when the upper lip is tense–– “Plucking the upper lip slightly with a tongue depressor and raising it slightly will tend to reduce the tension” (Nemoy and Davis, 1937, p. 48).
• Mirror:  Help a client understand the extent of his own facial and lip tension with a mirror.  Point out areas of tension, stiffness, and mottling.  Provide information about the face and lip muscles so that he can identify which muscles are holding excess tension.  Show him how specific tension interferes with his lip movements.
• Vibration and Raspberries:  Slow vibration can reduce tension in the lips as can production of the labial raspberries–– “Trilling the lips will assist in overcoming tension of the lips” (Nemoy and Davis, 1937, p. 53).  The fingers also can supply the vibration–– “Trilling the lips with the finger will help to relieve the tension” (p. 61).
• Warmth:  It is generally accepted that “neutral warm” temperatures between 95º and 98.6º relax muscles (Farber, 1982).  Use warm hands, blankets, or towels on the face.
• Slow stretch:  Slow stretch (elongation) of a muscle relaxes it.  Identify the muscles that are holding excess tension and stretch them.  Place the flat surfaces of the fingertips at the center of the muscle length, press into the belly itself, and slowly stretch from midline to the ends of the fibers.
• Facial massage:  A general facial massage can be employed to reduce tension throughout the face.  Slow, deep, rotary massaging movements are used commonly.  Study the anatomy of the face and make sure to reach each muscle group.
• Body stretching and rotation:  General relaxation of the whole body that is accomplished with slow stretch and rotation usually has a positive influence on face and lip tension.
• Body position:  Consult with team motor specialists about the best position for lip mobility when working with clients who have neuromuscular disorder.
• Reduction of stimuli:  Morris and Klein (2000) recommend reducing external distractions to help reduce lip retraction.
• Normalize oral-tactile sensitivity:  Employ methods to normalize oral-tactile sensitivity when it is a cause of lip retraction.  See our chapter on this topic for ideas.
• Saline solution:  Hanson and Barrett (1988) used liquid in the mouth to enact a slow stretch on the muscles of the lower lip by stretching them from the inside.  Make a saline solution by stirring a several shakes of salt into a glass of warm water.  Have the client take a sip of the solution and hold it between the lower lip and the lower teeth.  Hold it for 10 seconds and then spit it out.  Have the client continue this procedure until all the solution is used up. 

References

• Farber, S. D. (1982). Neurorehabilitation: A Multisensory Approach. Philadelphia: W. B. Saunders.
• Hanson, M. L., & Barrett, R. H. (1988). Fundamentals of Orofacial Myology. Springfield: Charles C. Thomas.
• Morris, S. E., & Klein, M. D. (2000). Pre-Feeding Skills: A Comprehensive Resource for Mealtime Development. Austin: Pro-Ed.
• Nemoy, E. M., & Davis, S. F. (1937, 1954 1969). The Correction of Defective Consonant Sounds. Magnolia, MA: Expression.