The Oral-Motor Debate

Recalling our earlier discussion here, I thought readers of "Early Intervention Speech Therapy" would be interested in an article, "Evidence-Based Systematic Review: Effects of Nonspeech Oral Motor Exercises on Speech" in the November 2009 issue of the American Journal of Speech-Language Pathology.

Best wishes,

Caroline

CITATION:

McCauley R.J., Strand E., Lof G.L., Schooling T. & Frymark, T. (2009, November). , American Journal of Speech-Language Pathology, 18, 343-360.

FURTHER READING:

http://www.speech-language-therapy.com/oralmotortherapy.htm

AUTHORS:

Rebecca J. McCauley

The Ohio State University, Columbus

Edythe Strand

Mayo Clinic and Mayo College of Medicine, Rochester, MN

Gregory L. Lof

MGH Institute of Health Professions, Boston

Tracy Schooling

Tobi Frymark

American Speech-Language-Hearing Association, Rockville, MD

Contact author: Tracy Schooling, National Center for Evidence-Based Practice in Communication Disorders, American Speech-Language-Hearing Association, 2200 Research Boulevard #245, Rockville, MD 20850-3289. E-mail: tschooling@asha.org.

ABSTRACT:

Purpose: The purpose of this systematic review was to examine the current evidence for the use of oral motor exercises (OMEs) on speech (i.e., speech physiology, speech production, and functional speech outcomes) as a means of supporting further research and clinicians' use of evidence-based practice.

Method: The peer-reviewed literature from 1960 to 2007 was searched for articles examining the use of OMEs to affect speech physiology, production, or functional outcomes (i.e., intelligibility). Articles that met selection criteria were appraised by 2 reviewers and vetted by a 3rd for methodological quality, then characterized as efficacy or exploratory studies.

Results: Fifteen studies met inclusion criteria; of these, 8 included data relevant to the effects of OMEs on speech physiology, 8 on speech production, and 8 on functional speech outcomes. Considerable variation was noted in the participants, interventions, and treatment schedules. The critical appraisals identified significant weaknesses in almost all studies.

Conclusions: Insufficient evidence to support or refute the use of OMEs to produce effects on speech was found in the research literature. Discussion is largely confined to a consideration of the need for more well-designed studies using well-described participant groups and alternative bases for evidence-based practice.

Key Words: oral motor treatment, evidence-based systematic review, speech disorders

http://ajslp.asha.org/cgi/content/abstract/18/4/343?etoc

http://ajslp.asha.org/cgi/content/full/18/4/343

I can tell you that oral motor strengthening DOES WORK. I don't care what anyone says or what manipulated research study supposedly "proves." I am a speech therapist AND a special needs teacher, and I use this and IT WORKS. End of discussion, as far as I'm concerned.

At Help Me Speak, LLC, we specialize in using a combination of structured oral motor exercises (Talk Tools, Beckman) and PROMPT to improve speech production and clarity for children with apraxia and autism.  All of our sessions, aside from being individualized for each child, incorporate structured oral motor ex with speech production/language activities using PROMPT as needed to improve speech production/clarity. So we are NOT using oral motor ex in isolation.  We work on improving the control/grading, stability, coordination, and dissociation of the jaw, lips, and tongue.  Yes, some ex work on strength/tone but not in isolation, but in relation to the skills I noted in the previous sentence.  

IF as an SLP you are using structured oral motor exercises, then  you are NOT doing tongue OUTSIDE the mouth activities (lip licking, lollipop licking,etc.).  YES, structured oral motor exercises DO work.  I can tell when my clients are NOT consistent with their homework.  It does make a difference!  

I agree with Pam Marshalla regarding oral-motor exercises and the definition of EBP---it's not all about the research BUT the combination of research, Clinician/SLP information, and the client's or parent's perspective.  

Yes, I agree that we need additional research but am wondering which parents would allow their child w/apraxia to join a study regarding structured oral motor ex in which they were part of the CONTROL group and did NOT receive struct. o-m or PROMPT.  How happy would they be with the therapy? How much progress would be made?

We have many children w/apraxia who did NOT make progress until they began working with our clinic.  

Refer to:

www.oralmotorinstitute.org

www.talktools.net

www.beckmanoralmotor.com

our site is www.helpmespeak.com

Barbara A. Taylor, M.S., CCC-SLP

Executive Director, Help Me Speak, LLC

THANK YOU CAROLINE BOWEN,

I am am an avid reader of yours and have learned a tremendous amount from you. I appreciate your questions posted!!!!!!

Hi hope I am not too late to post...someone stated that OM does nothing for kids with Down syndrome!  That is definitely not true as I have a daughter with DS and she could not produce many sounds as a toddler but successfully has mastered ALL sounds with OM.  Although she still dentalizes her tip alveolars it is adequate for intelligibility.  At birth she could not suck and swallow.  We did Beckman exercises but not right away as I did not have training.  Before Beckman we had to "pour" the liquid down her throat by squeezing the nipple ourselves.  Her suck was disorganized with her tongue going every which way.  With Beckman and thickened liquids she learned to suck and swallow.  Then we still had other feeding issues with fatigue, etc.  All the chewing and jaw stability things really helped here.  Today at 15 she can eat just about anything without gagging, a miracle in my eyes from where she was, but yes due to her low tone she occasionally leaves food stuck up in the right upper quandrant of her mouth and is unable to get it by bending her tongue upward and back so we use a tooth brush...maybe she needs more OM addressing this issue.  No I didn't do research on my daughter except I used my own eyes pre- post- treatment.  Again I have to say if you do OM without clearly knowing what you are working on of course it won't work...or understanding the process of skills needed in feeding and articulation.  %0d%0aSharon

If you give a look at the South of the continent they will find many investigations thereon, invite you to visit:

1. In Portuguese http://cefac.br

2.  In Spanish

http://www.asalfa.org.ar/

http://www.fonoaudiologiachile.cl/

I'm in a sort of whirl reading these posts. I know NOTHING about this sort of thing. In clinic, one supervisor advised me to get whistles for my client (nasal speech) and a higher supervisor nixed it (after I'd bought them!) saying, "We don't do that anymore". My program was very negative on OMT, to the point of saying "don't do it".  It was never mentioned except when we were assigned articles to prove it wasn't useful. I've been an SLP for two years now and really have started to wonder if there's something else I could do. I demonstrate and demonstrate, use tongue depressors for placement, but the error habits are stuck! I really don't know the first thing about the how (or why?) of massage, cheek puffing, gum chewing, etc. Somebody once told me a child's jaw was weak on one side and to have him chew gum. That's not for the lack of looking for info on ASHA!

Is there a good, one source, to get this information...where it doesn't assume any previous OMT knowledge? Thanks.

Thank you all so much for sharing your comments and research in our oral motor debate! As Lisa, CCC-SLP

Stephanie, in this post you stated

"In addition, I was taught that oral-motor therapy is one of the best and most effective ways to treat apraxia, which is also listed above as within our scope of practice."

In my graduate program, my course on motor speech disorders strongly emphasized that fact that apraxia is a motor planning problem, not one of motor weakness or discoordination.  Apraxia is not a disorder of weakness.   Why would oral-motor therapy help apraxia if the disorder is at the level of the brain, not the level of the muscles?

I think it's dangerous to be so dismissive of the research in this area, simply because it's all "one-sided". I doubt it's all some grand conspiracy where the studies supporting the use of NS-OMTs are being hidden away. Research has been done, and none to date has revealed a benefit. Fairly clear. Clear enough that during my schooling (2001-2003) use of them was not taught, with explanation why.

With all the money behind the selling of these products, and in theory, all the potential dollars that could be used by the industry for research and 'proof', I think it's even more telling that supportive studies do not exist.

I wouldn't sell yourself short - the other wonderful things that you are doing with your clients are obviously making a huge difference. It's not the magic of OMTs!

Stephanie,

Wow - you've certainly stirred the pot with this post - I am impressed with who's weighed in on the subject. In my short time as an SLP, I have found that "oral-motor therapy" means different things to different people - parents, other SLPs, OTs. It is really an all-encompassing term that we should use carefully and specifically, making sure we use techniques that make sense in terms of our goals and our patients' needs. I am of the belief that "if you want to elicit speech, use speech" but I don't disagree that blowing bubbles, using straws and making a lot of noise with a three year-old and horns doesn't bring an increased awareness to their mouth and how it can make sound. Thank you Pamalla, Caroline & Greg for reminding me of your important work, and to Stephanie for getting us to talk about this controversial subject yet again.

I think the oral motor controversy topic is very interesting. I am a 2nd year graduate student and I just finished an assignment in regards to nonspeech oral motor treatments (NSOMTs). The following is my assignment. The question provided to me by my professor was the following: "You are newly employed at Icicle Elementary school in Snowland School District.  You are reviewing treatment plans of the children who will move onto your caseload.  One child, age 4, is receiving treatment to reduce hypernasal resonance and there are several oral-motor techniques listed as part of her program. You decide that you had better conduct a review of the literature in support of and against using the oral motor treatment approach in preparation to take this child onto your caseload."

The following is my literature review and discussion.

1. Powell, T. (2008). An integrated evaluation of non-speech oral motor treatments. Language, Speech, and Hearing Services in Schools, 39, 422-427.

This article posses questions about nonspeech oral motor treatments (NSOMT). Those questions include: (1) are NSOMTs consistent with accepted theories of communication and learning?, (2) do NSOMTs “work”?, (3) do NSOMTs work better than more established options?, (4) for whom do NSOMTs work?, (5) how much NSOMT is optimal?, (6) are there contraindications to the implementation of NSOMTs?, (7) what is the ratio of benefit to cost?, (8) at what point is it ethical to consider NSOMTs appropriate for clinical use?

2.Lass, N. & Pannbacker, M. (2008). The application of evidence-based practice to non-speech oral motor treatments. Language, Speech, and Hearing Services in Schools, 39, 408-421.

“The purpose of this article was to help speech-language pathologists (SLPs) apply the principles of evidence based practice (EBP) to nonspeech oral motor treatments (NSOMT) in order to make valid, evidence-based decisions about NSOMTs and thus determine if they are viable treatment approaches for the management of communication disorders” (p.408). This article provides information about EBP, defines NSOMTs, and contains a literature review of NSOMTs articles from 1981 to 2006. This article found that the literature does not support NSOMTs for improving speech.

3.Ruscello, D.M. (2008). Nonspeech oral motor treatment issues related to children with developmental speech sound disorders. Language, Speech, and Hearing Services in Schools, 39, 380-391.

The purpose of this article was to define nonspeech oral motor treatments (NSOMT), provide theories for the use of NSOMTs, and review current research in regards to NSOMT. This article focused on literature pertaining to children with developmental speech sound disorders. This article does not support the use of oral motor treatments to improve speech for children with developmental speech sound disorders.

4. Kummer, A.W. (2008). Cleft palate and craniofacial anomalies: effects on speech and resonance (2nd ed.). Clifton Park, NY: Delmar Cengage Learning.

This textbook describes cleft lip/palate and craniofacial anomalies. Information includes assessment and treatment issues. Kummer, in Chapter 21, writes about past and current research in regards to nonspeech oral motor treatments for improving speech and resonance. Kummer states that treatment should be primarily a traditional articulation therapy for speech and for resonance, which is rarely targeted in speech therapy, using different feedback methods (i.e. auditory, visual, and tactile feedback) is useful. Kummer does not support the use of NSOMTs. (For more information see Chapter 21:Speech Therapy: Making It Simple, p.580 and 599)

5.Golding-Kushner, K.J. (2001). Therapy techniques for cleft palate speech and related disorders. San Diego, CA: Singular.

Golding-Kushner addresses therapy techniques that should be avoided in Chapter 9 of her textbook. “Exercises intended to increase lip, tongue, or jaw strength are inappropriate for several reasons. Strength of the articulators is not the reason for the errors” (p.134). Golding-Kushner does not support the use of using NSOMTs for clients with cleft palate who demonstrate compensatory articulation errors. She also does not support using NSOMTs for treating resonance disorders. “Mulitview videofluoroscopy has shown that velopharyngeal movement for these nonspeech functions differ from velopharyngeal movement for speech in the same speaker” (p.135). Also, “electromyographic (EMG) activity to levator palatini increases as oral pressure increase. Thus, the best “palatal exercise” is speech” (p.135).

7.Lof. Gregory. (2003). Oral motor exercises and treatment outcomes. Language Learning and Education.

Lof addresses oral motor exercises and treatment outcomes. First, Lof describes the functioning of the oral structures during speech and nonspeech activities. Then he examines the value of strengthening exercises for speech and evaluates whether nonspeech tasks are relevant to improving speech. Lastly, he reviews treatment studies that have used oral motor exercises for speech sound production improvement.

Discussion of the Literature:

Based the current literature and research review, there is no empirical evidence that nonspeech oral motor treatments (NSOMTs) are effective for speech sound or resonance disorders. A child with a cleft palate who is receiving therapy for either articulation or resonance issues should not be receiving NSOMTs within his or her treatment because it does not adhere to evidence-based practices (EBP). When examining the literature, there are many authors who are experts in the areas of cleft palate and speech sound disorders who do not support the use of NSOMT. Karen Golding-Kushner does not support the use of oral-motor exercises for improving speech. “Exercises intended to increase lip, tongue, or jaw strength are inappropriate for several reasons. Strength of the articulators is not the reason for the errors” (p.134).  Ann Kummer, another expert within cleft palate has a similar statement, “Patients with a history of cleft have a structural abnormality, not weakness of the musculature” (p. 599). Golding-Kushner also does not support oral motor treatments for improving resonance. She states that the clinician should avoid using palatal and velopharyngeal exercises such as palatal massage, icing, palatal strengthening exercises, and other similar exercises.

There is absolutely no relationship between the frequency and complexity of movements in the vocal tract during speech and nonspeech activities (Duffy, 1995; Johns, 1985; Robin et al., 1997). In fact, EMG activity of the velopharyngeal muscles is entirely different during speech and nonspeech activities (Trigos et al., 1988; Ysunza et al., 1999). Not surprisingly, there is no evidence that these activities result in improved velopharyngeal closure during speech or in decreased hypernasality (Powers & Starr, 1974; Ruscello, 1982; Star, 1990; Van Demark & Hardin, 1990) (p. 134-135).

Golding-Kushner also advises against blowing exercises because, again, there is no relationship between those exercises and speech.

Kummer, who was mentioned previously, wrote a textbook about assessing and treating children with cleft palate and craniofacial anomalies. In Chapter 21, “Speech Therapy: Making it Simple”, she has a section titled appropriately, “Oral-Motor Exercises (That Don’t Work!)”.  In this section, Kummer lists past and current information pertaining to NSOMTs. “In the past, clinicians used oral-motor ‘exercises’, such as blowing, sucking, whistling, cheek puffing, swallowing, and even playing wind instruments, in hopes of strengthening the muscles of the velopharyngeal valve for improved function” (p. 599). She also mentions how researchers tried to stimulate velopharyngeal movement through electrical stimulation, but these exercises did not demonstrate any improvement in VPC. “Later research showed significant differences in the velopharyngeal closure patterns of speech and nonspeech activities, suggesting that nonspeech ‘exercises’ could not possibly be effective in improving velopharyngeal function for speech” (p.599).

Lass and Pannbacker (2008) have also compiled a list of research/literature in regards to NSOMTs. They examined 45 articles/reports from 1981 to 2006. “The evidence for NSOMTs was found to be limited” (p.412). Most of the articles that they reviewed had evidence levels of IIb and III, which indicates that the research was usually a single-subject design with no controls; therefore, the strength of the study ranged from moderate to limited (i.e. the stronger the levels of evidence the better the research study). There was also limited outcome data. When examining articles that pertained to improving speech when using NSOMTs, only 2 out of 11 studies suggested that there was improvement. Those two studies were (McAlister, 2003) and (Polmanteer & Fields, 2002). However, these studies’ methodology and statistics are questionable. “Based on the lack of high-level evidence, NSOMTs should be excluded from use as a mainstream treatment until there are further data supporting their use” (p. 413).  

The rest of the literature that I reviewed (i.e. Lof, Ruscello, and Powell) all had similar outcomes and information in regards to NSOMTs.  Overall, NSOMTS should not be used to treat a speech sound or resonance disorders based on the fact that there is no supportive literature or research.  “Despite this information and the fact that there is no evidence in the literature to support the efficacy of nonspeech exercises in improving velopharyngeal function (Yorkston et al., 2001), some clinicians continue to incorporate these exercises in treatment due to a lack of knowledge” (p. 599). SLPs need to give their clients the best treatments that will produce the best outcomes.

I did not read all of the other blog postings, so I'm not sure if anybody has suggested these authors or researchers. From my limited experience as a working SLP, I have had not expereince with oral motor therapies. I would like to learn more. There's always that pedulum of experience vs. research. I thought I would just throw out what I had found being that your blog posting dealt with one of my assignments.

Dear Caroline ~

Thank you for the references you provided. There are some wonderful suggestions there and many of them I already use. I must admit however that for a number of the children I work with in EI who are under the age of three, they simply are not appropriate or possibly will be eventually once they are a little older, less orally defensive, etc. and are therefore ready for such techniques.

Reading your responses causes me to think our caseload and therapy experiences with children 0-3 have been very different.

My goal for this blog is to provide a forum where therapists and parents will feel comfortable to speak their mind, ask questions, offer ideas and suggestions, etc. As I have stated in numerous posts, I am not an “expert” in the field, nor do I pretend to be. Many therapists who work in EI home care find themselves feeling very isolated going from home to home each day without the benefit of other speech therapists with which to collaborate. This is why I created the blog – I wanted to share my ideas and hear what other therapists are doing and so that we all can improve our own therapeutic repertoire and perspective.

Thank you again for providing your point of view and expertise.

Stephanie

Dear Stephanie,

Thank you for re-stating the points you have already made. I had hoped that you would respond to my questions, and perhaps you will in due course. I won't clutter your blog by repeating them. Instead, I will attempt to respond to your desire to hear about "OTHER techniques".

"I would love to hear some of the OTHER techniques, if not oral motor based, therapists are using to elicit speech with children in birth-3, especially when the child is sensory-seeking and has very poor body/oral motor awarness [sic]." and "I look forward to hearing your recommendations and preffered [sic] treatment methods for eliciting speech production in children with very low tone and severe sensory needs in children ages 0-3."

As you would appreciate I develop dynamic treatment plans for individual children based upon initial and ongoing assessment. With the population of 0-3 children you describe, the younger they are the more I would be inclined to target language goals or "communication goals" and not speech goals per se. I am not sure how you are quantifying "VERY" low tone and "SEVERE" sensory needs, but I guess some children so classified are not destined to be "talkers" while others may turn out to be significantly late and/or highly unintelligible talkers who  benefit most from having a low or high tech AAC system.

With children who demonstrate appropriate readiness for work on speech, I favour:

1. Stimulability therapy (Miccio, 2009)

2. Dynamic Temporal and Tactile Cueing - DTTC, a form if Integral Stimulation (Strand, 2005; Gildersleeve-Neuman, 2007)

3. The techniques described in my pps here: http://www.speech-language-therapy.com/cas-very-young.pps

4. Techniques to elicit "many repeats" of a word or words: http://www.speech-language-therapy.com/andrew.pps

5. The intervention suggestions of Davis & Velleman (2000)

My recently published book (Bowen, 2009) includes accounts of a range of intervention approaches, procedures, techniques and activities. As well, there is excellent discussion of child speech development, disorders and intervention on the phonologicaltherapy list, here: http://health.groups.yahoo.com/group/phonologicaltherapy/

Best wishes,

Caroline

REFERENCES

Bowen, C. (2009). Children's speech sound disorders. Oxford: Wiley-Blackwell.

http://www.speech-language-therapy.com/cssd.html

Davis, B.L. & Velleman, S.L. (2000). Differential Diagnosis and Treatment of Developmental Apraxia of Speech in Infants and Toddlers. Infant Toddler Intervention: The Trans-disciplinary Journal, 10, 3, pp. 177 - 192.  http://speech-language-therapy.com/DavisVelleman2000.pdf

Gildersleeve-Neumann, C. (2007, Nov. 6). Treatment for childhood apraxia of speech: A description of integral and stimulation and motor learning. The ASHA Leader, 12(15), 10-13, 30. http://www.asha.org/publications/leader/archives/2007/071106/f071106a.htm

Miccio, A. W. (2009). First things first: Stimulability therapy for children with small phonetic repertoires. In C. Bowen, Children's speech sound disorders. Oxford: Wiley-Blackwell, pp. 96-101.  

Strand (2005). http://www.apraxia-kids.org/site/apps/nl/content3.asp?c=chKMI0PIIsE&b=788447&ct=1212055

Sherril ~

Thank you so much for bringing up a very important point!! I touched on this a bit with regards to increasing a child's "awareness" and "resistance" to certain foods and having their teeth brushed etc.; however you summarized perfectly how "oral defensiveness", overactive gag, etc. is why young children often need and can benefit from oral motor therapy.

Also as you stated, "more often than not, they are slow in their development of babbling, jargoning and talking". I see these issues everyday in my job in E.I, and to me, there seems to be a correlation. The whole purpose of this blog is to create conversation and provide a place for therapists to share ideas and dialogue. Thank you for saying so well what I failed to put into writing - Thank you for your contribution!!

Having read through many of these comments and Stephanie's blog entry, I find one aspect missing. Infants and  babies put everything into their mouths as part of exploring their worlds. According to some studies, in the child's first year, they learn more via their mouth exploration than they do from exploring with their eyes or hands. Having worked in Early Intervention for over 23 years, I would venture to say that the overwhelming majority of toddlers with speech delay, that I work with, did NOT bring things into their mouths, with the exception of their own fingers and sometimes not even that. The point here is that a toddler, by the time they reach their third year has been doing their own form of Oral Motor and Oral Sensory Therapy throughout their early development. When they  don't, more often than not, they are slow in their development of babbling, jargoning and talking.  Consequently, one of the primary reasons for doing what I call Oral Motor-Sensory Therapy is to try to make up for what they have lost in not actively and spontaneously mouthed toys.  My box of oral motor-oral sensory toys is labeled Mouthing Toys, plain and simple.

It has been my experience that many, if not most of the children will initially reject the various mouthing toys, because of their oral defensiveness, lack of experience and sometimes overactive gag reflex, but once having accepted them, they will often crave them. After being given the opportunity to mouth a variety of safe objects with varying properties of textures, size, shape, vibration and squishiness this craving diminishes and we have helped them normalize and organize their mouths. Just as when infants mouth toys, they begin to produce and play with more sounds, so do children receiving oral motor-sensory therapy.  That is to say, during the process of oral motor and oral sensory stimulation, the production of more sounds and more words is evident. If this is not "evidence based" therapy, I don't know what is.

Dear Caroline -

As I stated in both this post and my related comments:

"Two important points -

1. These techniques may not help everyone - it is not a one size fits all, but I have met success by using these techniques.

2. This is not a "one and done" approach. Parents need to buy into it and use lotion and massage with their child throughout the week. Doing oral motor work of any kind really needs to be practiced over time to see positive results. Also, like everything else, some kids respond better and quicker than others. "

Also:

"I know I do not have solid numbers and a published research study to support my belief or claims; however I see the benefits come to life everyday in many of the homes in which I work.

If there is no current research to support oral-motor therapy as a valid method to treat speech production, maybe we, as a professionals, need to conduct research studies and begin documenting our successes so that we have numbers to back up our hard work!! Just because the research isn't there, doesn't mean the techniques do not work."

And finally -

"I would love to hear some of the OTHER techniques, if not oral motor based, therapists are using to elicit speech with children in birth-3, especially when the child is sensory-seeking and has very poor body/oral motor awarness."

I look forward to hearing your recommendations and preffered treatment methods for eliciting speech production in children with very low tone and severe sensory needs in children ages 0-3.

Thank you for your contribution to the blog - I can appreciate your passion for your work!

Sincerely,

Stephanie

I didn't realize that there was still much controversy regarding oral-motor exercises for speech disorders. If a lotion massage will strengthen my muscles, sign me up and I can stop wasting all my time at the gym!

I have taken quite a bit of criticism for using oral motor exercises as part of speech therapy but only when the person (child or adult) has motor weakness.  I have found that many of the children I have treated (oh, roughly 40%) have dysarthria in addition to developmental speech delays.  I agree with you that adding jaw, tongue, palate and (sometimes) laryngeal exercises to strengthen muscles makes a big difference in the intelligibility of their speech in conversation.  I don't know what I did before I discovered the wonder of straws...long ones, short ones, fat ones, skinny ones. LOL

Thank you for your detailed response, Stephanie. May I unpack what you are saying a little with a few more questions?

RE: "Mobility - the more these activities are done, the more you help to relax the muscles. I work weekly with OTs and PTs that use lotion and massage to help either increase or decrease tone throughout the rest of the body (depending on the need)."

Maybe I am not understanding you correctly, but as you would know from your reading in the area of motor learning, constitutional low tone (idiopathic hypotonia) sometimes improves a little with age, but that essentially it is something an individual must accommodate to/compensate for, and that it cannot be altered by massage or exercise or vibration or other intervention. In order to become better informed I would love a reference, perhaps from the speech physiology, OT or PT literature to support what you are saying.

RE: "In my experience oral motor used in the same way has created the same benefits."

How remarkable! Have you documented this in single case studies? How do you measure "oral tone" pre- and post treatment?

"Strength - the more awareness and mobility a child has over their muscles, the more they move them, and thus increase strength over time."

I did not know that "the more awareness and mobility a child has over their muscles, the more they move them". Do you have a citation for this too? How does "more movement" increase strength of the oral musculature? What is the physiological mechanism for this change? Surely what you are suggesting is impossible.

RE: "Parents need to buy into it and use lotion and massage with their child throughout the week. Doing oral motor work of any kind really needs to be practiced over time to see positive results."

Does that mean you have done a study comparing lotion-massage and/or vibration/massage intervention with and without home practice?

Best wishes,

Caroline

These are all very interesting comments and I am so glad to see this discussion with differing points of view.  This is clearly a very emotional topic for people and clearly there are alot of people who have a career that they've built on the premise that OM tx. works.  

I have been an EI speech path for 12 years and, although I went through a phase, during which I tried OM, I do not use OM therapy today for my speech/language kids, including those w/ Downs Syndrome.  We cannot change the low tone of these kids.  I do not think that exploring 30 year old literature is valuable.  I also think that it's impt. that when we talk about therapy being successful that we have to remember that we don't know which part of the therapy was successful.  Was it the OM Tx. or the fact that you worked on speech?  Was it the OM Tx. or the fact that you've educated the parents on how to talk to their child in a way that will elicit speech?  Is it the OM Tx. or the fact that you've helped identify things that the child cares to request?  I believe the latter in all of the above examples.  

I hope that we'll continue to explore this topic and come to some conclusions.  I agree that OM tx. is very time consuming and my time with each of my little guys is very, very limited.  I don't want to spend it unwisely.

I agree with others.  Simply moving the tongue constitutes oral motor skill so of course it is an important part of treatment.  But to say that if a child simply blows a whistle they will make a particular sound is absurd.  I think the problems with oral motor have come from people trying to do something without clearly understanding what they are doing or what the outcome will be.  For example with a tongue thruster, you can work on correct swallowing and still have a tongue thruster because you didn't address the underlying problems such as tongue position at rest, unstable jaw, bad habits of nail biting, enlarged tonsils that occlude the airway.  The goals of oral motor are multiple: improving muscle strength, improving mobility, establishing independent movement of a particular muscle or muscle groups(you don't want the jaw to come forward every time the tongue comes forward, etc.), and the list goes on.  I have found that most children with articulation problems have very weak tongues along with other issues such as discrimination problems.  They cannot sustain a retracted tongue for any length of time so we work on tongue retraction in an "ee" position while maintaining contact with the upper back molars...and this along with tongue tip elevation exercises can improve speech greatly if it is done in conjunction with auditory discrimination drills of error sounds versus target sounds.  So I guess what I am saying is that yes oral motor works but it needs to be used along with other strategies too.  I only had one case in 30 years of treatment where oral motor did not work in some capacity to improve speech function and the child was later diagnosed with some type of regressive neurological disease where she eventually stopped walking.

To address some of the questions out there regarding how using lotion and vibration/massage can improve "mobility, awareness and strength", my response is quite simple and straightforward. MANY of the children I work with in EI have  sensory-based needs which are often directly impacting their oral motor function. They are therefore very resistent to brushing teeth, eating different food textures, poor chew/bite, minimal mouth movement when attempting speech, etc.

Using oral motor massage with/without lotion and vibration, as well as a wide variety of other techniques, slowly breaks down the child's resistance to touch/sensation and also increases their acceptance of assistance and prompting with both speech and feeding experiences.

Awareness - when you use lotion, vibration, massage, etc of any kind, you bring awareness to the area being touched. Many of my kiddos can't stick out their tongue or pucker their lips. Doing oral motor activities helps them to be able to follow these simple motor movements as well as make them more accepting of tactile cues.

Mobility - the more these activities are done, the more you help to relax the muscles. I work weekly with OTs and PTs that use lotion and massage to help either increase or decrease tone throughout the rest of the body (depending on the need). In my experience oral motor used in the same way has created the same benefits.

Strength - the more awareness and mobility a child has over their muscles, the more they move them, and thus increase strength over time.

Two important points -

1. These techniques may not help everyone - it is not a one size fits all, but I have met success by using these techniques.

2. This is not a "one and done" approach. Parents need to buy into it and use lotion and massage with their child throughout the week. Doing oral motor work of any kind really needs to be practiced over time to see positive results. Also, like everything else, some kids respond better and quicker than others.

Hope this helps!!

**I would love to hear some of the OTHER techniques, if not oral motor based, therapists are using to elicit speech with children in birth-3, especially when the child is sensory-seeking and has very poor body/oral motor awarness.

p.s. To Pam Marshalla - thank you for your contributions to this post. I agree with you!! I think there are times when therapists become "hung up" on the evidence and research instead of simply using what works for each child based upon their individual needs.

Let me address this notion that "wagging the tongue" has nothing to do with articulation. Wagging the tongue has everything to to with articulation for many reasons. Let me describe two basic ones:

1. Charles Van Riper, the "Father of Articulation Therapy" wrote that the first step in remediating speech error often is one of "vivifying" movement. To vivify speech movements means to pay less attention to any one specific oral movement but instead to explore and experiment with a wide variety of oral movements. The idea is that any new movement is a change in the right direction. “Variation must precede approximation” (Van Riper, "Speech Correction: Principles and Methods", 1978, p. 187).

In regard to the tongue, Van Riper wrote: “The tongue must take flight to locate new targets. It must be helped to move in unfamiliar ways in its search for the desired target sound. It must be trained to scan and to explore.” (Van Riper, "Speech Correction: Principles and Methods", 1964, p. 136).

2. Speech movements are a refined smaller set of movements that emerge out of a larger gross set. When we teach a child to "wag his tongue", we are teaching him to use a gross tongue movement first from which we will later teach him to use more mature and refined movements. The traditional articulation therapy writers called this "increasing the flexibility of the articulators" (Berry & Eisenson, "Speech Disorders: Principles and Practices of Therapy", 1956, p. 139).

In modern times, we call it "increasing range of movement." Range of motion, as it relates to bodily movement, refers to the extent to which the body can flex and extend, lateralize left and right, and rotate around its axes. SLP's utilize techniques to help clients increase range of jaw, lip, and tongue movement so that appropriate movements for speech sound production can be achieved over time. Babies learn the full range of tongue movements - like wagging it back and froth - from which the baby will learn to restrict his tongue movements into the smaller patterns required for speech.

Here are some quotes from articulation texts that reflect this idea:

1925/Very early artic text: “Have the patient perform lip, tongue, lower jaw and soft palate exercises calculated to give these organs increased flexibility and hence greater capacity to adjust themselves in new positions” (Borden and Busse, "Speech Correction", 1925, p. 182).

1956/Classic traditional articulation therapy text in the style of Van Riper: “Practice in intensifying the visual and kinesthetic cues will affect articulatory flexibility to a degree” (Berry and Eisenson, 1956, p. 139).

1995/Modern motor speech therapy text: “Stretching exercises, such as sustained maximum jaw opening; sustained maximum tongue protrusion, retraction, or lateralization; or sustained maximum lip retraction, pursing, and puffing may have some effect on increasing range of motion and decreasing effects of spasticity on speech” (Duffy, J.R. (1995) "Motor Speech Disorders: Substrates, Differential Diagnosis, and Management", p. 398-399).

This is how you merge Oral Motor Techniques with an Evidence-Based Practice: You study the definition of EBP.

Every definition of EBP states that it is a three-fold process of pulling together what you lean from the LABORATORY, what you gain from CLINICAL EXPERIENCE, and what the PATIENT WANTS.

EBP IS NOT JUST THE USE OF SO-CALLED "PROVEN" TECHNIQUES!

Here are some definitions that may help you better understand what an EBP is:

1. From the originator of the subject: “Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values.” [Sackett, D. et al. (2000) Evidence-Based Medicine: How to Practice and Teach EBM, 2nd edition. Edinburgh: Churchill Livingstone.]

2. Paraphrased from the ASHA website: The goal of EBP is the integration of clinical expertise, best current evidence, and client values to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve.

3. From a university textbook: "EBP is the conscientious, explicit, and judicious integration of best available external evidence from systematic research, internal evidence from clinical practice, and evidence concerning the preferences of a fully-informed patient." [Dollaghan, C. A. (2007) "The Handbook for Evidence-Based Practice in Communication Disorders. Baltimore: Brooks]

Also read this quote about creativity from one of the best SLP writers of our time:  

“The emphasis placed on the use of experimentally evaluated techniques is not meant to discourage creative clinical work. Clinicians should always be willing to try new techniques.”

[from: Hegde, M. N. (1998) Treatment Procedures in Communicative Disorders. Austin: Pro-Ed. (p. 48)]

This notion that an SLP can do in therapy ONLY those things which have been proven in a research lab is a mistaken application of the term EBP. An evidence-based practice INTEGRATES laboratory evidence with clinical expertise.

Oral means "mouth". Motor means "movement".

We are using oral motor techniques every single time we are engaged in articulation work.

For example:

If you ask a client to lift his tongue-tip to the alveolar ridge to produce an /l/, you are adjusting his oral movements.

If you ask him to open his mouth a little wider, or to lift the tongue tip a little higher, you are adjusting his oral motor skills a little more.

When you use a toothette to mark the point on the alveolar ridge where he is supposed to make contact with the tongue-tip, you are giving him a tactile cue to adjust his oral movements.

When you have the client hold his tongue-tip up to the alveolar ridge while you count to ten, you are developing his oral motor skills.

When you have him say "love", "like" and "lollipop" with good tip elevation, you are exercising his oral motor skills.

This argument over whether or not we should be doing "oral motor therapy" is ridiculous.

If the term "oral motor" scares you, use the term "mouth movement". Articulation therapy includes adjustments to "mouth movements". There is no way around this.

Dear Stephanie,

I read your article What's In Your Oral-Motor Toolkit? (April 2009) with interest. In your toolkit you have the following tools that you use every day at work: a mirror, lotion, handheld back massagers, Nuk, chew tube and chew cord, whistles and whistle activated toys, bubbles, cotton balls, feathers, pinwheels, other things children can blow, pictures and an electric toothbrush.

The use of lotion caught my eye. You write “use lotion on the child's face—cheeks, chin and above their upper lip—to increase strength, mobility and awareness of the oral musculature. If the child will allow it, I try to do hand over hand so that they are massaging their own face.” Can you explain for me (1) how massage increases the strength of the oral musculature; (2) how massage increases mobility of the oral musculature; and (3) the benefits of massaging with lotion as compared with massaging without lotion.

With regard to handheld back massagers you say,  “I use the massagers similar to how I use the lotion. The vibration offers stimulation on the oral muscles to help increase awareness, strength and mobility.” How does this form of massage (1) strengthen the oral musculature and (2) improve its mobility?

In this current article called “The Oral Motor Debate” (August 2009), you say “I myself am a huge supporter of oral-motor therapy and use it almost everyday with the majority of the children I treat in EI.” Are you also a huge supporter of Evidence Based Practice, and if so, how do you marry the two (i.e., OMT and EBP)?

Best wishes,

Caroline

Caroline Bowen PhD CPSP

ASHA Fellow

Speech Language Pathologist

9 Hillcrest Road

Wentworth Falls NSW 2782

Australia

e: cbowen@ihug.com.au

i:  http://www.speech-language-therapy.com  

The reason that there are workshops by these individuals is primarily that these presenters own companies and they put on their own workshops.  Also, others may have heard the workshop, liked it and then pass that on to others who are planning workshops.  

Basically anyone can have a workshop.  If you fill in the paperwork correctly, you can also have the workshop eligible for ASHA CE credits if you have successfully completed the procedures to be an ASHA CE Provider or solicit an approved provider as a partner.  There are no questions asked about whether your workshops have an evidence basis to them, though this is encouraged.

what about the works of Char Boshart and Pam Marshalla ?????

why are there always work shops offered on the topic????

some of the stuff works for some of the kids....it's not the" be all and end all" answer......

Stephanie,

You went to ASHA's website to determine their position on oral-motor therapy, but the information you gave states the disorders we work on, not the methods supported to treat those disorders. Yes ASHA says we work on oral anamolies and apraxia, but it does not say we work on them through oral-motor therapy. Personal accounts may say oral-motor therapy works, but how do you know it is the oral-motor therapy making the difference? How do you know it is not something else being done within your therapy or in the child's environment.  Research is definitely needed! I want to use therapy methods that have research to back them up, so I can say to a parent, here is proof that this works.  Not, "he said this worked for his kid." I completed my graduate education in the last few years and oral-motor therapy was strongly discouraged throughout all courses.  At the same time, I seems as though we hear "oral motor therapy doesn't work" but we aren't told what DOES work! We are in a difficult position. But, personally would rather say I did what I could with the research that backed me up, not I did what I could based on what I "thought" would work.

Unfortunately, it is true that there is no research to substantiate the use of "nonspeech" related oral motor activities for the purpose of improving speech production.  Our organization hears from many parents who want to know why their child is not progressing in speech therapy.  When we describe what we do know about effective treatment for children with apraxia of speech, the parents are very disappointed that their child has primarily been given nonspeech oral activities such as blowing, licking peanut butter, etc. and there is no progress. Time and time again, when the same child is given appropriate speech therapy for speech motor planning issues, the child starts to make nice gains. Parents do not want to see their child's precious time wasted.  

When evidence does not exist for a particular approach, we should ask ourselves, "Should it work?"  Theoretically, why should it work.  Speech therapy that incorporates principles of motor learning is what appears to be most effective for children with apraxia of speech.  Blowing bubbles, biting, and licking and other such activities do not in any way reflect what IS known about motor learning.  And there is some research, limited as it is, that suggests these nonspeech activities do not work to improve speech production in children with speech sound disorders.

This is a great source for people to read:

Seminars in Speech and Language

Issue 04

Controversies Surrounding Nonspeech Oral Motor Exercises for Childhood Speech Disorders

Guest Editor Gregory L Lof Ph.D.

Volume 29

November 2008

Here is one recent abstract for an article everyone here should read:

Am J Speech Lang Pathol. 2009 Jul 28. [Epub ahead of print]Links

   Click here to read

   Evidence-Based Systematic Review: Effects of Non-Speech Oral Motor Exercises on Speech.

   McCauley RJ, Strand E, Lof GL, Schooling T, Frymark T.

   The Ohio State University, Columbus, OH.

PURPOSE: The purpose of this systematic review was to examine the current evidence for the use of oral motor exercises (OME) on speech (i.e., speech physiology, speech production, and functional speech outcomes) as a means of supporting further research and clinicians' use of evidence-based practice.

METHOD: The peer-reviewed literature from 1960 to 2007 was searched for articles examining the use of OME to affect speech physiology, production or functional outcomes (i.e., intelligibility). Articles that met selection criteria were appraised by two reviewers and vetted by a third for methodological quality then characterized as efficacy or exploratory studies.

RESULTS: Fifteen studies met inclusion criteria; of these, eight included data relevant to the effects of OME on speech physiology, eight on speech production, and eight on functional speech outcomes. Considerable variation was noted in the participants, interventions, and treatment schedules. The critical appraisals identified significant weaknesses in almost all studies.

CONCLUSIONS: Insufficient evidence to support or refute the use of OME to produce effects on speech was found in the research literature. Discussion is largely confined to a consideration of the need for more well-designed studies using well-described participant groups and alternative bases for evidence-based practice.

I think ASHA cleary supports the position that there is not evidence for oral motor exercises and that they should not be freely used until there is.  Numerous articles show that the strength and coordination necessary for speech sounds is less than 10% of the maximum strength possible from the musculature, therefore even weak oralmotor skills should be enough to produce speech sounds. That being said, I do think there is a difference between activities to make a child aware of their mouths and oral motor exercises.  You can do brief awareness exercises, but shouldn't speech always be included? How do blowing exercises do anything for speech or speech awareness?

From ASHA 2008

http://lshss.asha.org/cgi/reprint/39/3/408

"The Evidence Base in NSOMTs

Despite their popularity, there is a paucity of evidence for

NSOMTs as an effective method for improving speech and nonspeech

activities. Sufficient evidence concerning their effectiveness

does not exist. As Kamhi (2006c) pointed out, the greatest

concern about the use of oral motor exercises is the absence of data

indicating that they are effective in improving speech production

skills. Nonetheless, NSOMTs continue to be used as a treatment

by many SLPs. However, based on a lack of high-level evidence,

NSOMTs should be excluded from use as a mainstream treatment

until there are further data supporting their use. It is important

that SLPs consider the evidence supporting or refuting a treatment

method in order to make the best clinical decisions as well

as for the appropriate allocation of resources rather than wasting

time on less effective methods. Thus, NSOMTs should, at best, be considered “experimental” until there are well-designed institutionally

approved research studies designed to assess their efficacy.

SLPs are obligated to obtain informed consent for experimental

treatment. This includes documentation of (a) the type of treatment

to be provided, (b) the nature and purpose of the proposed treatment,

and (c) possible risks and benefits of the treatment (Aiken,

2002).

"Movements that do not imitate speech should not be used and are not useful in the remediation of speech sounds:

–“there is no relevance to the end product of speaking by using anexercise of tongue wagging, because there are no speech sounds that require tongue wagging”(Lof, G. L., 2003).

–“The goal of speech therapy is NOT to produce a tongue wag, to have strong articulators, to puff out the cheeks, etc. Rather, the goal is to produce intelligible speech”(Lof, G. L., 2006).

–“no speech sound requires the tongue tip to be elevated toward the nose; no sound is produced by puffing out the cheeks; no sound is produced in the same way as blowing is produced.Oral movements that are irrelevant to speech movements will not be effective as speech therapy techniques”(Lof, G. L., 2006)."