Tagged "Renee Roy Hill"

Ask A Therapist: Using Vibration for Low Muscle Tone

Posted by Deborah Grauzam on

Hi TalkTools,


I have a question about using vibration (as with the DnZ-Vibe or Vibrator & Toothettes). I understand that vibration can be used to "wake up" the sensory system, and I believe I’ve heard that it can have a temporarily positive effect on low muscle tone. I’ve read that vibration should be used in short durations, but I was wondering if you had any guidelines for the maximum or minimum duration of vibration? I’m thinking especially in a case of low muscle tone as in children with Down Syndrome.


Thank you very much!




Hi Riley,

I’m Renee, a TalkTools® Instructor, and I would be happy to help you. This is an excellent question, I am asked this many times when teaching and working with clients!

You are correct, vibration can give the muscle more input and therefore often trigger a better motor response, thus “waking up” or “stimulating” the muscle to move. There are no specific “time” or duration guidelines for this. It is our responsibility as the therapist to look at the motor response while providing the input. So for some children with significantly low tone and an extremely under-responsive sensory system, it may take longer for the muscle to respond. But for a child who may have a better sensory system, the client may only need quick input 1-2x to see the motor response. It is important to remember what specific motor movement you are looking for and that the stimulation given is causing the appropriate reaction.

For example if I am providing stimulation to the lateral margin of the tongue to facilitate tongue tip lateralization to the back molars, once I see the movement, the vibration has done its job. Then I need to decide if my goal is repetitive movement using the vibration - leading me to possibly provide the input several times until I no longer see the tongue tip follow the stimulus - or possibly to quickly transition that movement to function (i.e. placing a cube of food on the back molar so the client then uses the movement in a functional way) which is my highest priority but sometimes not yet obtainable in my first sessions with the client.

Once I am sure of the goal of the vibration stimulation (what am I looking for in the motor system) it is easier to determine how long I should use it! The goal is always to eventually eliminate the vibration so that the movement is then stimulated through functional activities such as eating and speaking.

I hope this helps!

Renee Roy Hill, MS, CCC-SLP

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Ask A Therapist: Horn #9

Posted by Deborah Grauzam on

Hello TalkTools,


I purchased the Horn Kit about a year ago, and the Horn #9 (airplane) in my kit does not have the propellers on it. My husband was informed via a recent email that they were taken off as a precaution because they could pose a choking hazard.


My son is now at this horn in the Horn Program, and his therapist is not sure how to assess whether he is doing this horn correctly without the propellers. With previous patients of hers, if both propellers spun, then she could tell the child was blowing hard enough/correctly. She is now not sure how to assess when my son is ready to move to the next horn, since the propellers are not there.


Can someone please tell us how to assess this horn correctly?


Thank you for your time!




Hi Brianna,

I'm Renee, a TalkTools® Instructor, and I would be happy to answer your question.

You are correct, the new horn #9 does not have propellers, but not to worry, the movement of the propeller is not the determining factor of duration.

What your therapist will want to do is “listen" for a 2-second blow that is steady and controlled using a stable jaw, cheek tension, lip protrusion and abdominal grading. Although the propellers added a “fun” factor, the goal is not to make them move. The movement of the propellers actually led to some clients trying to blow too hard, so I believe the removal of the propellers has really improved the horn!

I hope this helps!

Renee Roy Hill, MS, CCC-SLP

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Ask A Therapist: Tips for Implementing the Horn Hierarchy

Posted by Deborah Grauzam on

Hello Talktools,


I'm a pediatric SLP with a clinical question for your experts. I attended the Three-Part Treatment Plan for Oral Placement Therapy (OPT) workshop last year. I have a little guy (3;4) who presents with low tone, has a breathy voice and speaks in short bursts.


I recently introduced the Horn Program, hoping that we could use it to improve his abdominal grading and breath support. However, we are having some problems with compensatory movements, and I'm having trouble remembering from the workshop what we are supposed to do about that!


When I hold up the horn, he leans, opens his mouth wide and reaches for it with his arms. If I can get him to sit back in the chair as I bring the horn to him, he inevitably opens his mouth wide. He also bites the horn for stability, and if I can get him to close his mouth as I present the horn, he grabs my shoulder for support.


I feel we need to back up, but I'm not sure where to go! Would one of the TalkTools® Instructors be able to help me with this? Do these sound like things his OT should work on? Are there some other activities you might recommend as a prerequisite for success with Horn #1?


Thank you in advance for any guidance on this issue.






Hi Kim,

This is a common problem when starting with a client, especially if he is just beginning an OPT program, has overall low tone and also has jaw instability and difficulty with lip-jaw dissociation. The aforementioned are all good reasons to use the TalkTools Horn Hierarchy. Following are some things to remember about using the Horn Program that may be helpful.

1. Consider your seating - Is he well supported with his head, pelvis, knees and ankles at 90 degrees? Does he have a place to rest his hands, head and feet? These are important to think about initially, remembering that what happens in the body often is seen in the mouth. If you do not have access to good support from a chair, try lying him down on the floor (I like a wedge if possible, but if you are working in a home you may only have access to a pillow). Gravity can help him with stabilizing the body, and if he’s not working against his own lack of support through his core muscles, you may get a better start.

2. It is absolutely OK to provide jaw support when starting out. If you remember, you can also progress forward through Horn #1 and #2, even if you are still needing to give him support. Jaw support can help and is crucial in eliminating a few of the problems you are reporting: Moving forward (you are providing stability at the lowest level of oral function and often need good support to start. Think about getting his body and jaw positioned first with your support and THEN present the horn. Doing both at once often leads to habitual compensatory movements), controlling the opening of the jaw (increase your support as needed until he opens just wide enough - if he still has difficulty, think about where you are in his Jaw Program. If you are just beginning and he has poor jaw control, this may not be something you can completely control just yet, working on a jaw program simultaneously- the TalkTools® Bite Tube Set and/or the TalkTools® Jaw Grading Bite Blocks will help! You may also want to consider supporting him from behind if his chair seems to be supporting him OK at the hips, knees and feet but he has nowhere for his hands or head to stabilize. In this case, you would use your body as the support from behind while wrapping your hand around the head to support the jaw. This can also eliminate some of the leaning forward you may see, especially if he is seeking stability/sensory input.

3. If you continue to struggle, consider backing up and working with Step B of the Bubble Blowing Program to teach him to control airflow; this is where you blow the bubble and catch it on the wand, having him use a voiceless “ha” to teach him to isolate the abdominals. This would take out the focus of lip closure and jaw stability for now, while teaching him to access volitional air with control. I’d also really consider your jaw program, and see if several sessions of jaw input might help you gain a little more control over his oral function.

All great questions and I hope these suggestions help you find a starting point. Of course if it leads to more questions, please don’t hesitate to contact us again!


Renee Roy Hill, MS, CCC-SLP

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Ask a Therapist: Proper Tongue Elevation & Retraction

Posted by Deborah Grauzam on

Dear Therapists


I need advice please! I am seeing a 5 year old child with severe childhood apraxia of speech together with dysarthria (specifically weakness of tongue and lips). So far his lip strength and movement has improved a lot, but I am really struggling with his tongue. He can protrude his tongue beautifully, retraction we are working on, but he is doing ok so far. Lateral movements we are also working on, but tongue elevation seems impossible!  Both posterior and anterior tongue movements just aren't happening! Any advice will be appreciated!!!


Kind Regards




Hi Denise,

Thank you for your email.  I understand your frustration!  I can tell you in looking at motor development, tongue tip elevation does not occur if you do not yet have retraction and stability along with lateral border stability which all allow the tongue tip to develop so it may just be a matter of continuing to work on the underlying skills necessary for tongue tip dissociation.  Often, children who have motor planning deficits in conjunction with oral motor weakness can progress at a rather slow pace and therapy can be difficult when compared to children who only have dysarthria.  I'm happy to help you sort out what might be missing!  I often find that the order I do treatment in can be as important as the exercise itself.  For example, many children with CAS and Dysarthria have difficulty isolating the motor skill I'm looking for, thus a good sensory-motor program may be useful immediately before targeting the motor task I have as a goal.

I'm not sure what education you have in TalkTools but the Three Part Treatment Plan teaches of our systematic approach to motor speech disorders based on normal development. I look forward to hearing from you!

Renee Roy Hill, MS, CCC-SLP


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Ask a Therapist: Jaw Instability and Parent "Homework"?

Posted by Deborah Grauzam on

Hi TalkTools,


I recently completed the self-study course "A Three Part Plan for Oral Placement Therapy." Really enjoyed the course and hoping to use the knowledge with patients. I have 2 questions to start:


1) I see that the jaw assessment is done with bite blocks and then the bite blocks are used for therapy as well, if jaw instability exists. I am confused as to when the bite tube hierarchy is used. I see that the bite tube hierarchy (hierarchy for strength and compression) is used for ages birth to 3, but I believe bite tubes can be used for adults as well. So, when do you recommend the use of bite blocks versus bite tubes?

We do use the Bite Tube Hierarchy for the birth to 3 population. Not only is this hierarchy developing jaw grading (the up and down jaw movement we are looking for in speech), it also facilitates the chewing movement we need for feeding. Since it does not require the same cognitive skills that the TalkTools Jaw Grading Bite Blocks requires for teaching bite and hold, our young clients can do this activity. You are correct that we can use this tool at any age both for feeding, if we are working on teaching chewing skills or for speech, or if we want to reinforce the jaw grading necessary for syllables.

The Bite Blocks have been one of our best tools for developing jaw grading (because it isolates the jaw in multiple positions and works to increase skill at the position) as well as teaching a client the motor plan for the specific positions needed for speech. We often use them in conjunction with the Bite Tube Hierarchy because each gives the client a different sensory-motor experience, working both in movement and in isolation. So it is not always an either/or choice. If appropriate, I always assess in both hierarchies, analyze the results and then determine my goals. If both tools can provide input and skill the client is missing, I may do both with a client.

2) Sara says on DVD that parents need to do homework 3x per week and that if parent is only going to do it 2x per week, child is not likely to progress. The homework manual mentions that if parents don't return the folder, homework will not be sent home and child will progress at slower rate. I see patients once weekly. If parents don't wish to be involved in homework, can the child progress? What has your experience been with this?

This can be tricky as we as therapists try to make decisions on the best therapies to use. Sara is referring to the literature stated in exercise physiology. If a muscle is not worked regularly then we cannot change the function of the muscle. In our experience we've seen this and often with children who have special needs and sensory-motor based speech and feeding deficits more frequent exercise is necessary to change muscle function. If a family is not involved and working at home, you are more than likely not going to see changes in their muscle function.

Remember that this program as a whole allows multiple opportunities to practice the same functions. For example, we may target jaw grading through the TalkTools Bite Tube Hierarchy, TalkTools Jaw Grading Bite Blocks, chewing solids on the back molars, gum chewing or the slow feed technique. I might be able to encourage a family to practice gum chewing and chewing on the back molars at meals 2-3X during the week while I focus on the Bite Blocks and Bite Tubes in therapy. Even though we are performing different activities we are targeting the same muscles and therefore they are getting practice throughout the week. Although the ideal is always that the client practices daily in all areas of the desired home program, in reality we know this may be difficult. The best way to determine if the therapy is making a change in function is to take good data. If you are seeing progress, you are more than likely on track! If I don't see progress over a months time, my tendency is to look at why and change my approach or my goals.

My experience has been that if I can give a family just one activity to work on, then point out the successes we see in that technique, I can often get them on board for supporting this program. The most important piece of information parents need is understanding what it is they are doing, why they are doing that activity, and how it is going to impact their goals. I have to question why a family is seeking speech and language services if they do not want to participate in assisting me in working toward their goals. The more I can reinforce their successes, however small, the more involved they may become! I hope this helps!

Renee Roy Hill, MS, CCC-SLP

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