This presentation is going to be held at the Texas Speech-Language & Hearing Association 2017 Annual Convention, Thursday. Feb. 23, noon-1:30 p.m.

Author: Renee Roy Hill, MS, CCC-SLP

Abstract:

Discuss treatment of clients diagnosed with apraxia of speech and related motor speech disorders. Explore 1) Childhood Apraxia of Speech 2) Related Motor Speech Disorders 3) Van Riper’s Phonetic Placement Approach 4) the importance of tactile and proprioception in shaping speech movements for speech, 5) shaping placement of the articulators using tools.

Learning outcomes: 

1. Participants will be able to list at least three characteristics of Childhood Apraxia of Speech and Dysarthria.
2. Participants will be able to list at least two goals of a tactile treatment approach.
3. Participants will be able to implement three phonetic placement methods.

Summary: 

Children with motor based speech disorders such as Dysarthria and Childhood Apraxia of Speech (CAS) present with a speech sound disorder in which precision and consistency of movements underlying speech are impaired. CAS may impact both non-speech and speech movements. CAS may also coexist with disorders of muscle strength and tone such as dysarthria. As infants and toddlers, children with CAS may have limited babbling, limited expression, but seemingly typical receptive skills. Older children with CAS may have poor oral imitation skills, erratic speech sound errors, and lack of a verse phonemic repertoire (Kaufman 2013).  Unfortunately, there is no specific, validated list of diagnostic features of CAS which differentiates this disorder from other types of speech sound disorders (ASHA, 2007), however the research is emerging. 

This presentation will attempt to identify key diagnostic features of both CAS and Dysarthria and discuss when Oral Placement Therapy (OPT) may be beneficial.  While it is always the goal to work on verbal output and speech production, some children with CAS have such severe motor planning issues, or co-morbid muscle based issues that they are non-verbal, or have very limited verbal output. Tactile cueing techniques such as PROMPT (Grigos,2010), or The Kaufman Speech Praxis Therapy (Kaufman, 2007) may prove positive results for some children; however others may need even more work on the sensory-motor system to gain foundational skills necessary for speech (Kaufman, 2007). Kaufman suggests that in order for these therapies to be successful, the child must be able to imitate, sit and attend, and execute gross motor movements on command. In addition, oral motor weakness should not be the primary disorder. For these children, sensory integration, oral motor stretching and toning and speech sound shaping may be needed (Kaufman 2007). There is no question that working on oral-motor skills should not be done is isolation of speech production when dealing with apraxia (Marshalla, 2000), but rather as Oral Placement Therapy (OPT) which is a term suggested by Bahr and Rosenfeld Johnson (2010.)

OPT is a modern extension of Phonetic Placement Therapy (Van Riper, 1954) and The Feedback Model (Mysak, 1971). It is based on a very common sequence (Bahr 2001, Crary 1993, Hayden 2004, Marshalla 2004, Rosenfeld Johnson 1999, 2009, Young and Hawk 1955):   

• Facilitate speech movement with the assistance of a therapy tool (ex. horn, tongue depressor) or a tactile-kinesthetic facilitation technique (ex. PROMPT facial cue);
• Facilitate speech movement without the therapy tool and/or tactile-kinesthetic technique (cue fading);
• Immediately transition movement into speech with and without therapy tools and/or tactile-kinesthetic techniques.

For children with motor speech disorders, this sequence can be helpful if the child cannot form the necessary placement of the articulators to produce sounds. Repetition and reinforcement is helpful based on motor learning theory (Hammer, 2007; Mysak 1971.) To improve speech, one must work on speech (Jakielski, 2007); however one must consider those children who have very limited verbal output (Merkel-Walsh, 2012).

The concept of “bridging” which is movement to speech based on muscle memory is an effective therapy technique (Roy-Hill, 2013). For example if a child has limited lip rounding to produce a /w/ , blowing bubbles can be used to reinforce lip rounding through tactile cueing, and as soon as movement is noted the tool is faded (Van Riper 1958) and speech sound drills can begin.

Clinicians must use evidenced based practice (EBP) to determine therapeutic treatment (ASHA, 2005). It is important to remember that EBP is not only limited to double blind studies, but an “approach in which current, high-quality research evidence is integrated with practitioner expertise and client preferences and values into the process of making clinical decisions (ASHA, 2007). Client progress and clinical data are important factors when determining treatment, and certainly the Phonetic Placement Approach (Van Riper , 1957) has been widely documented in the field of speech pathology. In addition, sensory-motor and oral tactile teaching techniques have clinical data to support their use (Bathel, 2007; Bahr & Rosenfeld-Johnson, 2010). Through muscle and motor based placement skills , therapists can effectively improve speech clarity in children who present with CAS. 

References:

American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech [Technical report] available from www.asha.org/policy

Bahr, D., Rosenfeld-Johnson, S. (2010). Treatment of Children With Speech Oral Placement Disorders (OPDs): A Paradigm Emerges. Communication Disorders Quarterly, XX(X), 108.

Lof, G.L. (2007). Reasons why non-speech oral motor exercises should not be used for speech sound disorders. Presentation at the ASHA Annual Convention, Boston, MA. Nov. 17.

Roy-Hill, R. (2013). A Sensory-Motor Approach to Apraxia of Speech and Related Motor Speech Disorders [Live presentation].

Van Riper, C. (1958, 1954, 1947) Speech Correction: Principles and Methods. Englewood Cliffs: Prentice-Hall.

by Robyn Merkel-Walsh, MA, CCC-SLP

This poster was presented at the 2016 annual ASHA Connect Convention, Poster Session #PS02.

Download the poster here  

ABSTRACT

Presentation explores 1) traditional versus phonological therapy, 2) the sensory-motor system as it relates to speech, 3) the importance of tactile and proprioception in articulation therapy, 4) shaping placement of the articulators to improve speech clarity.  

LEARNER OUTCOMES

1. Participants will be able to differentiate phonological versus traditional articulation therapy.  

2. Participants will be able to define the three stages of Van Riper’s Phonetic Placement Approach.  

3. Participants will be able to use at least three oral placement cues in order to facilitate speech movements.  

DISCUSSION

Two widely used models of articulation therapy include the traditional and phonological models (Bowen, 2005). While studies suggest that the phonological model may prove more positive results than the traditional model (Klein, 1996), Van Riper’s Phonetic Placement Approach (PPA) may be more useful for individuals who are not be able to achieve placement cues (Van Riper, 1978). In 1958, Van Riper stated:

"Every available device should be used to make the student understand clearly the positions of the tongue, jaw, and lips to be assumed."

Placement cues are based on the more traditional models of therapy, and rely on the concept that an individual can copy the motor plan suggested by the therapist, such as “place your tongue tip to the spot.” Therapists, however, often struggle with a population of individuals who do not respond well to “look at me and say what I say,” and those who require a tactile-kinesthetic approach to treatment (Bahr & Rosenfeld-Johnson, 2010). Individuals with dysarthria, dyspraxia and/or myofunctional disorders may make slow progress, or no progress at all, without the assistance of tactile cues. Even though therapists have heard the debate on oral motor therapy (Bowen, 2006; Lof, 2006; Lof, 2007; Lof, 2009), clinicians are still widely using the techniques because they yield positive treatment outcomes (Bahr, 2008).

Clinicians, who represent the Board of Directors for the Oral Motor Institute, have struggled with distinguishing “oral motor therapy” from the form of “Non Speech Oral Motor Exercises” (NSOME) presented by Gregory Lof (Lof, 2008). The term “Oral Placement Disorder” (OPD) was coined by Diane Bahr and Sara Rosenfeld-Johnson in 2010 (Bahr & Rosenfeld-Johnson, 2010). Children with OPD cannot imitate targeted speech sounds using auditory and visual stimuli (i.e., “Look, listen, and say what I say”). They also cannot follow specific instructions to produce targeted speech sounds (e.g., “Put your lips together and say m”). Although the term OPD is new, the concepts surrounding the term have been discussed by a number of authors and clinicians (Bahr, 2010; Hodge, 2012; Marshalla, 2007).

There has been question, and ongoing confusion, as to what is a NSOME, versus what is an oral placement technique (OPT) (Bahr & Rosenfeld-Johnson, 2010). Oral Placement Therapy (OPT) is a tactile teaching technique used for children and adults with Oral Placement Disorders (e.g., dysarthria), who cannot learn standard speech sound production using auditory and visual teaching methods alone. OPT facilitates the pre-requisite skills in muscle control to develop dissociation and grading in the muscles of the abdomen, velum, jaw, lips and tongue for clients who cannot approximate the standard speech sounds using the instructions. If the client can produce standard speech using adequate placement and duration using only auditory and visual cueing, OPT would not be included in that client’s program plan.

Gregory Lof’s research has even stated that the methods used in Van Riper’s Phonetic Placement Approach are not in fact considered NSOME (Lof, 2009). This is why it is important to explore current clinical techniques to determine what activities are considered unrelated to speech production, as opposed to those activities that in fact are an extension of Phonetic Placement Therapy (Marshalla, 2007).

OPT IS A MODERN EXTENSION OF PHONETIC PLACEMENT THERAPY

(Van Riper, 1954) and The Feedback Model (Mysak, 1971).

It is based on a very common sequence (Bahr, 2001; Green, Moore & Reilly, 2000; Marshalla, 2007; Young and Hawk, 1955):

1. Facilitate speech movement with the assistance of a therapy tool (ex. horn, tongue depressor) or a tactile-kinesthetic facilitation technique (ex. PROMPT facial cue); use every available device (Marshalla, 2012);

2. Facilitate speech movement without the therapy tool and/or tactile-kinesthetic technique (cue fading);

3. Immediately transition movement into speech with and without therapy tools and/or tactile kinesthetic techniques.

PHONETIC PLACEMENT THERAPY TOOLS

MODERN ORAL PLACEMENT THERAPY TOOLS

REFERENCES

Bahr, D. (2008). The oral motor debate: Where do we go from here? Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Chicago, IL. (Full handout at http://convention.asha.org/handouts.cfm)

Bahr, D. (2001). Oral motor assessment and treatment: Ages and stages. Boston: Allyn and Bacon.

Bahr, D. & Rosenfeld-Johnson, S. (2010). Treatment of Children With Speech Oral Placement Disorders (OPDs): A Paradigm Emerges. Communication Disorders Quarterly, XX(X), 108.

Bowen, C. (2005). What is the evidence for oral motor therapy? ACQuiring Knowledge in Speech, Language and Hearing, Speech Pathology Australia, 7, 3, 144-147.

Green, R., Moore, C. A., & Reilly, K. J. (2000). The sequential development of jaw and lip control for speech. Journal of Speech, Language and Hearing Research, 45, 66-79.

Hodge, M. M. (2002). Non-speech oral motor treatment approaches for dysarthria: Perspectives on a controversial clinical practices. Perspectives in Neurophysiology and Neurogenic Speech Disorders, 12 (4), 22-28.

Klein, E. S. (1996). Phonological/traditional approaches to articulation therapy. Language, Speech, and Hearing Services in Schools, Vol. 27, 314-323.

Lof, G. L. (2007). Reasons why non-speech oral motor exercises should not be used for speech sound disorders. Presentation at the ASHA Annual Convention, Boston, MA, Nov. 17.

Lof, G. L. (2009). Nonspeech oral motor exercises: an update on the controversy. Presentation at ASHA Annual Convention, New Orleans, LA.

Lof, G. L. (2006). Logic, theory and evidence against the use of non-speech oral-motor exercises to change speech sound productions. Invited presentation at the ASHA Annual Convention, Miami, FL, Nov. 17.

Lof, G. L. & Watson, M. (2005). Survey of universities’ teaching: oral motor exercises and other procedures. Poster presented at the annual meeting of the American Speech-Language-Hearing Association, San Diego, CA.

Lof, G. L. (2004). Ask the Expert: A response by Gregory L. Lof, PhD., CCC-SLP. The Apraxia-Kids Monthly, 5 (1).

Lof, G. L. & Watson, M. (2004). Speech-language pathologist’s use of non-speech oral-motor drills: National survey results. Poster presented at the annual meeting of the American Speech-Language-Hearing Association, Philadelphia, PA.

Lof, G. L. (2003). Oral motor exercises and treatment outcomes. Perspectives on Language Learning and Education, 10 (1), 7-11.

Marshalla, P. (2007). Oral motor techniques are not new. Oral Motor Institute, 1(1). Available at www.oralmotorinstitute.org.

Marshalla, P. (2012). Horns, whistles, bite blocks, and straws: A review of tools/objects used in articulation therapy by Van Riper and other traditional therapists. Oral Motor Institute, 4 (2). Available at www.oralmotorinstitute.org.

Mysak, E. (1971). Speech pathology and feedback therapy. Charles C. Thompson Publisher.

Van Riper, C. (1958, 1954, 1947). Speech Correction: Principles and Methods. Englewood Cliffs: Prentice-Hall.

Young, E. H. & Hawk, S. S. (1955). Moto-kinesthetic speech training. Stanford, CA: Stanford University Press.

Good news! The American Academy of Private Practice in Speech Pathology and Audiology (AAPPSPA) has accepted a position statement TalkTools® Instructor Robyn Merkel-Walsh proposed on Oral Motor Therapy.

American Academy of Private Practice in Speech Pathology and Audiology (AAPPSPA) Position Statement - Oral-motor Therapy

Originally posted on AAPPSPA website.

By Robyn Merkel-Walsh, MA, CCC-SLP

Foreword:

In order to investigate Evidenced Based Practice in regards to oral-motor therapy, an AAPPSPA committee was formed. This Position Statement was written with input and editing from: Susan Arnold MS, CCC-SLP , Kaye Baumgardner MS, CCC-SLP/COM, Mary Billings MS, CCC-SLP/COM, Amanda Chastain MA, CCC-SLP, COM and Denise Dougherty MA, CCC-SLP.

Abstract:

The American Academy of Private Practice in Speech Pathology and Audiology (AAPPSPA) is a non-profit organization of speech and language pathologists (SLP) and audiologists who work in the private sector. Members of AAPPSPA foster the highest ideals and principles of private practice in speech pathology and audiology (AAPPSPA, 2015). Due to the continued controversy surrounding oral-motor therapy, the AAPPSPA board found it necessary to investigate this topic and forge a position statement. This position statement explores 1) defining Non-Speech Oral-Motor Exercises (NSOME), 2) defining Oral Placement Therapy (OPT), 3) understanding the difference between NSOME and OPT, 4) clinical implications for Evidenced Based Practice (EBP).

Discussion:

By analyzing AAPPSPA discussions, it is noted that many therapists in our organization supplement phonological and traditional models with oral-motor activities to help the patient achieve placement cues, especially for those individuals with muscle-based and motor-based diagnoses. Discussions involving NSOME, Myofunctional therapy, feeding and OPT can be frequently found in list-serve discussions. It was also noted, that not all AAPPSPA members were in support of oral-motor therapy due to lack of EBP; therefore this topic required further review. Clinicians who are a member of AAPPSPA must use EBP to decide if they want to reject the use of oral-motor and OPT based on the evidence, or look into the most appropriate treatment parameters based on the recipient of the treatment, and the diagnosis (Clark, 2005).

The ongoing question is whether or not oral-motor therapy is evidenced based. EBP according to the American Speech and Hearing Association is the integration of best research evidence with clinical expertise and patient values (ASHA, 2005). There is a misconception that EBP is limited to double-blind studies when in fact EBP is very centered on valuing feedback from the individual receiving treatment, and the clinical data collected in therapy. Not every method in the field of speech pathology has a large sampled, double blind study. For example, there is no proof that using a mirror aides in articulation therapy, but many therapists and patients report the value of mirror use when learning to imitate speech sounds. In addition, a single study can prove, that another study is not valuable. No single study has proven that oral-motor, OPT or Myofunctional therapy is an invalid or unethical therapy method.

Over the past decade, there has been an ongoing debate, through secondary research studies between those who do not support the use of Non-Speech Oral-motor Exercises (NSOME) (Bowen, 2005; Bowen , 2013; Lof, 2006; Lof, 2007; Lof, 2009 ), and those who support the use of Oral Placement Therapy (OPT) (Bathel, 2007; Bahr, 2008; Bahr & Johnson, 2010; Marshalla, 2007). Neither camp has large sampled double-blind studies to support their case; however, both sides of the debate have supported their hypothesis via secondary research such as literature review and surveys (Lof & Watson, 2005; Bahr, 2011.)

Oral-motor therapy is an umbrella term that leads to confusion (Bahr & Rosenfeld-Johnson, 2010.) Pre-feeding exercises, NSOME, Myofunctional therapy, strengthening exercises, swallowing exercises, oral imitation tasks and the use of oral speech tools were all being associated with the term oral-motor therapy (Marshalla, 2007). Thus far, there is no debate in the field of speech-language pathology that oral-motor exercises can prove positive results on disorders of feeding.

The term oral-motor therapy is in fact the appropriate term to describe exercises to strengthen the musculature, and regulate sensory-motor dysfunction for individuals who present with oral phase feeding disorders. This may include but is not limited to: dysarthria, Moebius syndrome, Down syndrome, Cerebral palsy, and Orofacial Myofunctional Disorders (OMD). SLPs involved in the treatment of oral-phase feeding disorders, have evidenced based support from sources such as: The International Journal of Orofacial Myology and the ASHA SIG13 committee publication Perspectives on Swallowing and Swallowing Disorders (Dysphagia). Numerous research articles have been dedicated to the use of oral-motor therapy in respect to the oral phase of feeding. In particular the relevance of oral sensory-motor function has been documented in the literature (Overland, 2010).

Over thirty-five years ago, the International Association of Orofacial Myology (IAOM) was formed, and has addressed the need for regulated educational opportunities and standardized college level credentialing of therapists to treat Orofacial Myofunctional Disorders (OMD) (Snow, 2015). Experts in Myofunctional therapy understand the connection between the airway, dentition and tongue posture, swallowing, and speech clarity. The Myofunctional Clinic of Bellevue has compiled an excellent list of EBP to support the use of Myofunctional therapy with a variety of individuals (Bellevue, 2015). Gommerman & Hodge produced a study analyzing the effectiveness of Myofunctional therapy and sibilant production and found that articulation therapy was achievable in only four therapy sessions after a tongue-thrust disorder was remediated in Myofunctional therapy (Gommerman & Hodge, 1995).

Clinicians, who represent the Board of Directors for the Oral-Motor Institute, have struggled with distinguishing oral-motor therapy, from the form of NSOME presented by Dr. Gregory Lof (Lof, 2008). The controversy in the field was causing much confusion; therefore, the term Oral Placement Disorder was coined by Diane Bahr and Sara Rosenfeld-Johnson in 2010 (Bahr & Rosenfeld-Johnson, 2010). The two practicing clinicians wanted to define that the therapeutic techniques being used to support speech sound productions were not the same types of activities that were suggested in the current literature, such as puffing air in the cheeks or tongue wagging (Lof, 2008). There is some misconception that speech-language pathologists (SLPs) who work on oral-motor issues, are not working on speech, and this is not the case (Merkel-Walsh & Bahr, 2014).

OPT, which is a form of tactile intervention, is used to create the standard placement for the targeted speech sound and is then immediately transitioned into direct work on that targeted speech sound (Marshalla, 2007). The major difference between NSOME and OPT noted, was that NSOME are movements which are not related to speech sounds, while OPT therapy only includes speech-like movements (Bahr & Rosenfeld-Johnson, 2010). OPT follows the principles of Van Riper’s Phonetic Placement Therapy (PPT), and uses tactile cueing to help individuals who cannot respond to visual-verbal treatment cues (Marshalla, 2008). Children with Oral Placement Disorders (OPD) cannot imitate targeted speech sounds using auditory and visual stimuli (ex. look, listen, and say what I say). They also cannot follow specific instructions to produce targeted speech sounds (e.g. put your lips together and say /m/). Although the term Oral Placement Disorder is new, the concepts surrounding the term have been discussed by a number of authors and clinicians (Green, Moore & Reilly, 2000; Pannbacker & Lass, 2002; Polmanteer & Fields, 2002; Pruett-Hayes, 2005).

Despite this clarification in 2010, there have been continued questions, and persistent confusion, as to what constitutes a NSOME, versus what is an OPT technique (Bahr & Rosenfeld-Johnson 2010). OPT is a tactile teaching technique used for children and adults with Oral Placement Disorders (e.g., dysarthria), who cannot learn standard speech sound production using auditory and visual teaching methods alone. OPT facilitates the pre-requisite skills in muscle control to develop dissociation and grading in the muscles of the abdomen, velum, jaw, lips and tongue for clients who cannot approximate the standard speech sounds using the instructions. If the client can produce standard speech using adequate placement and duration using only auditory and visual cueing, OPT would not be included in that client’s treatment plan (Merkel-Walsh, 2014).

OPT is a modern extension of Phonetic Placement Therapy (Van Riper, 1954) and The Feedback Model (Mysak, 1971). It is based on a very common sequence (Young and Hawk, 1955; Van Riper, 1978). Gregory Lof’s research has stated that the methods used in Van Riper’s Phonetic Placement Approach, are not in fact considered NSOME (Lof, 2009). Merkel-Walsh and RoyHill (2014) presented this concept at the ASHA Convention:

1) Facilitate speech movement with the assistance of a therapy tool (ex. horn, tongue depressor) or a tactile-kinesthetic facilitation technique (ex. PROMPT facial cue);

2) Facilitate speech movement without the therapy tool and/or tactile-kinesthetic technique (cue fading);

3) Immediately transition movement into speech with and without therapy tools and/or tactile-kinesthetic techniques.

Conclusion:

Based on literature review and analysis of current articles, journal entries, podcasts, texts and monographs, it is determined that it is important to explore current clinical techniques to determine what activities are considered ethical and meaningful to an individual seeking private based speech pathology services. Being both sides of the debate have equal evidence by way of primary and secondary research, it should therefore be AAPPSPA’s position that:

1) Oral-motor therapy is an acceptable treatment method for those individuals who present with disorders of strength and tone, oral-phase feeding deficits and/or Orofacial Myofunctional Disorders. This may include the oral-phase of feeding, oral resting posture, drooling, and overall appearance of the oral-facial musculature. Oral-motor therapy encompasses activities that target the improvement of strength, tone, dissociation and grading of the oral musculature and usually involves regulation of the oral sensorymotor system (Overland, 2010). Oral-motor therapy for strength, tone and the oral-phase of feeding and been accepted in the field without debate.

2) Oral Placement Therapy, a form on Phonetic Placement Therapy, is an acceptable form of treatment methodology for those individuals who do not progress from purely traditional or phonological methodology. The individuals may also present with disorders of muscle strength and tone (OPD), and cannot respond accurately to look at me and say what I say. This therapy utilizes the implementation of therapy tools, in order to provide tactile cues to shape oral placements into speech sound production (Bahr & Rosenfeld-Johnson, 2010; Marshalla, 2007). Once the individual can imitate the sound(s) through traditional methods, direct work on speech sound production should be implemented.

3) The combination of oral-motor therapy and Oral Placement Therapy may be presented concurrently. An individual may present with a comorbid diagnosis (e.g., low tone and an Orofacial Myofunctional Disorder) that requires implementation of both oral-motor and Oral Placement Therapy simultaneously.

4) Myofunctional therapy is an acceptable form of therapy for those patients who present with Orofacial Myofunctional Disorders. These patients may also present with articulation errors that do not resolve with traditional models of therapy. The connection between tongue placement, swallowing, dental alignment and sibilant production has been thoroughly supported by the International Association of Orofacial Myology. Clinical evidence has been documented repeatedly by active Orofacial Myologists to indicate direct correlation between remediation of Orofacial Myofunctional Disorders and persistent speech sound disorders.

References:

American Academy of Private Practice in Speech Pathology and Audiology (AAPPSPA). 2015. Retrieved from : http://www.aappspa.org/.

American Speech-Language-Hearing Association. (2005). Evidence-Based Practice in Communication Disorders [Position Statement]. Available from www.asha.org/policy.

Bathel, J. A. (2007). Current research in the field of oral-motor, muscle-based therapies: response to: Logic, theory and evidence against the use of non-speech oral-motor exercises to change speech sound productions by Gregory Lof. TalkTools, Charleston, SC.

Bahr, D. (2008, November). The oral-motor debate: Where do we go from here? Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Chicago, IL. Bahr, D., Rosenfeld-Johnson, S. (2010). Treatment of children with speech oral placement disorders (OPDs): a paradigm emerges. Communication Disorders Quarterly, XX(X), 108.

Bahr, D. (2011) . The oral-motor debate part I: understanding the problem. The Oral-Motor Institute. Available from www.oralmotorinstitute.org.

Bowen, C. (2005). What is the evidence for oral-motor therapy? Acquiring Knowledge in Speech, Language and Hearing, Speech Pathology, 7, 3, 144-147.

Bowen, C. (2013). Controversial practices and intervention for children with speech sound disorders. Retrieved from: http://www.speech-language-therapy.com/pdf/nsome2013.pdf

Clark, H. M. (2005). Clinical decision making and oral-motor treatments. The ASHA Leader, pp. 8-9, 34-35.

Gommerman, S. & Hodge, M.M. (1995). Effects of oral Myofunctional therapy on swallowing and sibilant production. International Journal of Orofacial Myology, 21:9-22.

Green, R., Moore, C. A., Reilly, K.J. (2000). The sequential development of jaw and lip control for speech. Journal of Speech, Language and Hearing Research, 45, 66-79.

Klein, E.S. (1996). Phonological/traditional approaches to articulation therapy: a retrospective group comparison. Language, Speech, and Hearing Services in Schools, 27, 314-323.

Lof, G. L., & Watson, M. (2005). Survey of universities ‘teaching: oral-motor exercises and other procedures. Poster presented at the annual meeting of the American Speech Language-Hearing Association, San Diego, CA.

Lof, G.L. (2006). Logic, theory and evidence against the use of non-speech oral-motor exercises to change speech sound productions. Invited presentation at the ASHA Annual Convention, Miami, FL. Nov. 17.

Lof, G.L. (2007). Reasons why non-speech oral-motor exercises should not be used for speech sound disorders. Presentation at the ASHA Annual Convention, Boston, MA. Nov. 17.

Lof, G. L., & Watson, M. (2008). A nationwide survey of non-speech oral-motor exercise use: Implications for evidence-based practice. Language, Speech, and Hearing Services in Schools, 39, 392-407.

Lof, G.L. (2009). Nonspeech oral-motor exercises: an update on the controversy. Presentation at ASHA Annual Convention, New Orleans, LA

Marshalla, P. (2007). Oral-motor techniques are not new. Oral-motor Institute, 1(1). Available from www.oralmotorinstitute.org.

Merkel-Walsh, R. (2015). Conversations in speech pathology. Retrieved from: http://www.conversationsinspeech.com/.

Merkel-Walsh, R. (2014). Oral Placement to speech: transitioning muscle-memory into speech sound production. TalkTools. Charleston, SC.

Merkel-Walsh,R. & Roy-Hill, R. (2014). Using tactile techniques to improve speech clarity in children with childhood apraxia of speech. ASHA Annual Convention, Orlando, FL.

Merkel-Walsh, R. & Bahr, D. (2014). What evidenced based sensory-motor treatments are effective for speech disorders? Retrieved from: http://www.agesandstages.net/qadetail.php?id=31.

Mysak, E. (1971). Speech pathology and feedback therapy. Charles C. Thompson Publisher.

Overland, L. (2010). A sensory-motor approach to feeding. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 20, 3, 60-64.

Pannbacker, M., & Lass, N. (2002). The use of oral-motor therapy in speech-language pathology. Poster session presented at the annual meeting of the American Speech Language-Hearing Association, Atlanta, GA.

Polmanteer, K., & Fields, D. (2002). Effectiveness of oral-motor techniques in articulation and phonology treatment. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Atlanta, GA

Pruett-Hayes, S. (2005). Comparison of two treatments: Oral-motor and traditional articulation treatment. Poster session presented at the annual meeting of the American Speech Language-Hearing Association, San Diego, CA.

Snow, M. (2015, March 13). International Association of Orofacial Myology. Retrieved from IAOM: http://www.iaom.com/history.html

Van Riper, C. (1978). Speech Correction: Principles and Methods (6th Edition). Englewood Cliffs: Prentice-Hall.

Young, E. H., & Hawk, S. S. (1955). Moto-kinesthetic speech training. Stanford, CA: Stanford University Press.

By: Robyn Merkel-Walsh, MA, CCC-SLP & Sara Rosenfeld-Johnson, MS, CCC-SLP This poster was presented at the 2015 annual ASHA Convention, Session #9333, Poster Board #602.

INTRODUCTION

Presentation explores 1) defining Non-Speech Oral Motor Exercises, 2) defining Oral Placement Therapy, 3) understanding the difference between NSOME and OPT, 4) clinical implications for Evidenced Based Practice.

Two widely used models of articulation therapy include the traditional and phonological models (Bowen, 2005). While studies suggest that the phonological model may prove more positive results than the traditional model (Klein, 1996), Van Riper’s Phonetic Placement Approach may be more useful for individuals who are not be able to achieve placement cues (Van Riper, 1978). Many therapists supplement phonological and traditional models with oral motor activities to help achieve placement cues, especially for those individuals with muscle-based and motor-based diagnoses (Marshalla, 2007). Over the past decade, there has been an ongoing debate, through secondary research studies between those who do not support the use of Non-Speech Oral Motor Exercises (NSOME) and those who support the use of Oral Placement Therapy (OPT). Neither camp has large sampled double-blind studies to support their case; however, both sides of the debate have supported their hypothesis via literature review and surveys (Bahr & Rosenfeld-Johnson, 2010; Lof & Watson, 2005).  

LEARNER OUTCOMES

1. Participants will be able to differentiate a NSOME from an OPT technique.

2. Participants will be able to define the three stages of a phonetic placement cue.

3. Participants will be able to use at least three oral placement cues in order to facilitate speech movements.  

DISCUSSION

NSOME are movements which are not related to speech sounds, while OPT therapy only includes speech-like movements. OPT follows the principles of Van Riper’s Phonetic Placement Therapy (PPT), and uses tactile cueing to help individuals who cannot respond to visual-verbal treatment cues. Children with Oral Placement Disorder (OPD) cannot imitate targeted speech sounds using auditory and visual stimuli (ex. look, listen, and say what I say). They also cannot follow specific instructions to produce targeted speech sounds (e.g. put your lips together and say /m/). Although the term Oral Placement Disorder is new, the concepts surrounding the term have been discussed by a number of authors and clinicians (Bahr & Rosenfeld-Johnson, 2010). OPT facilitates the muscle placement to produce the targeted standard speech sound. If the client can produce standard speech using adequate placement and endurance using only auditory and visual cueing, OPT would not be included in that client’s treatment plan.

OPT is a modern extension of Phonetic Placement Therapy (PPT) as taught by Van Riper (1978) and follows The Feedback Model by Mysak (1971). It is based on a very common sequence:

1. Facilitate speech movement with the assistance of a therapy tool (ex. horn, tongue depressor);

2. Facilitate speech movement without the therapy tool and/or tactile-kinesthetic technique (cue fading);

3. Immediately transition movement into speech with and without therapy tools and/or tactile-kinesthetic techniques.  

NSOME	OPT
As quoted from Dr. Gregory Lof in 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."	Puffing air in cheeks during blowing is not used in OPT.Abdominal grading for phonatory control, jaw stability and jaw-lip-tongue dissociation are important for speech sound production.The use of a therapeutic horn can help shape the articulators into the placements required for the bilabial sounds /m, b, p/. That tool is quickly faded once the individual has the muscle-memory skill to produce the correct oral placement without the tool in the mouth.
As quoted from Dr. Gregory Lof in 2003:"There is no relevance to the end product of speaking by using an exercise of tongue wagging, because there are no speech sounds that require tongue wagging."	This movement is not related to speech so should not be used in speech therapy sessions. Tongue wagging is not used in OPT.Stimulation of the lateral margins of the tongue with vibration, elicits elongation of the tongue and can assist in creating the tongue tip tension needed to elevate the tip to the incisive papillae for / n, t, d, l /.
As quoted from Dr. Gregory Lof in 2009:"NSOME encourages gross and exaggerated range of motion, not small, coordinated movements that are required for talking."	OPT only works on small, coordinated movements that are similar to speech.Blowing a bubble with appropriate placement of the articulators assists with lip rounding using the correct jaw posture for the high jaw vowels /w/, /u/ and /o/. We immediately practice those sounds without the therapy tool as per Van Riper’s PPT.

Clinical data supports the relationship between OPT and speech clarity. The graph below reflects data collected from sessions with a 6 year old male with labial paresis. Lip closure on a flat-mouthed horn and bilabial production progress were monitored. When lip closure on the horn improved so did bilabial production. In sessions where lip closure was not as positive bilabial clarity decreased.

CONCLUSION

Dr. Gregory Lof’s research has stated that the methods used in Van Riper’s Phonetic Placement Approach, are not in fact considered NSOME (Lof, 2009). It is important to explore current clinical techniques to determine what activities are considered unrelated to speech production, as opposed to those activities that in fact are an extension of Phonetic Placement Therapy (Marshalla, 2007). If therapists understand the current debate, and that a NSOME is not the same as OPT; there would be less confusion amongst professionals in regard to evidence based practices when working towards improved speech clarity. Clinicians must use EBP to decide if they want to reject the use of a therapy technique based on the evidence, and look into the most appropriate treatment parameters based on the recipient of the treatment, and the diagnosis (ASHA, 2005). This new understanding of how OPT is used to create the standard placement for speech production would then encourage university-based researchers to explore why practicing SLPs report they use this therapy with good results. The next step would be large sample, double blind studies that would definitively address the use of OPT for clients with muscle-based speech clarity disorders.

REFERENCES

American Speech-Language-Hearing Association. (2005). Evidence-Based Practice in Communication Disorders [Position Statement]. Available from www.asha.org/policy.

Bahr, D., Rosenfeld-Johnson, S. (2010). Treatment of children with speech oral placement disorders (OPDs): a paradigm emerges. Communication Disorders Quarterly, XX(X), 108.

Bowen, C. (2013). Controversial practices and intervention for children with speech sound disorders. Retrieved from: http://www.speech-language-therapy.com/pdf/nsome2013.pdf

Klein, E.S. (1996). Phonological/traditional approaches to articulation therapy: a retrospective group comparison. Language, Speech, and Hearing Services in Schools, 27, 314-323.

Lof, G. (2003). Oral motor exercises and treatment outcomes. SIG 1 Perspectives on Language Learning and Education, Vol. 10, 7-11.

Lof, G. L., & Watson, M. (2005). Survey of universities teaching: oral motor exercises and other procedures. Poster presented at the annual meeting of the American Speech-Language-Hearing Association, San Diego, CA.

Lof, G.L. (2006). Logic, theory and evidence against the use of non-speech oral-motor exercises to change speech sound productions. Invited presentation at the ASHA Annual Convention, Miami, FL. Nov. 17.

Lof, G.L. (2009). Nonspeech oral motor exercises: an update on the controversy. Presentation at ASHA Annual Convention, New Orleans, LA.

Marshalla, P. (2007). Oral motor techniques are not new. Oral Motor Institute, 1(1). Available from www.oralmotorinstitute.org.

Mysak, E. (1971). Speech pathology and feedback therapy. Charles C. Thompson Publisher.

Van Riper, C. (1978). Speech Correction: Principles and Methods (6th Edition). Englewood Cliffs: Prentice-Hall.

Young, E. H., & Hawk, S. S. (1955). Moto-kinesthetic speech training. Stanford, CA: Stanford University Press.

NOTE: This article has been reprinted with permission from Diane Bahr of Ages and Stage®, LLC and Robyn Merkel Walsh.

Robyn Merkel-Walsh, MA, CCC-SLP & Diane Bahr, MS, CCC-SLP, CIMI

EVIDENCE-BASED PRACTICE (EBP) IN SPEECH-LANGUAGE PATHOLOGY

According to the American Speech, Language, and Hearing Association (ASHA, 2005) “the term evidence-based practice [EBP] refers to an approach in which current, high-quality research evidence is integrated with practitioner expertise and client preferences and values into the process of making clinical decisions.” Note that this approach to treatment encompasses practitioner expertise and client preferences in addition to high-quality research. In June 2011, Dr. Paul Rao (ASHA’s president at the time) said, “EBP is not about identifying the one best approach – it is about deciding which among the many acceptable options is likely to work best for a particular individual.” So, we are going to talk about acceptable oral sensory-motor treatment for speech disorders.

THE TRUTH ABOUT ORAL-SENSORY MOTOR TREATMENT FOR SPEECH DISORDERS

For many years, it was rumored that oral sensory-motor treatment was ineffective for treating the sensory-motor process of speech. Therefore, the Oral Motor Institute (OMI) was formed “to publish monographs that demonstrate the evidence base of oral sensory and motor techniques for articulation, motor speech, and feeding treatment” (Oral Motor Institute, n.d.). The OMI conducted a thorough and systematic review of the claim that oral sensory-motor treatment was ineffective in the treatment of speech problems. This process included extensive journal literature review (Bahr, 2008; Bahr, 2011, Sept.; Bahr, 2011, Nov.; Bahr & Banford, 2012) and textbook review (Marshalla, 2007, 2008, & 2012) which revealed:

• There are effective oral sensory-motor treatments for speech disorders
• There is a large body of journal and textbook literature regarding oral sensory-motor treatments for speech disorders
• ASHA supports research that provides evidence on the efficacy of oral sensory-motor treatments for speech disorders
• Oral Placement Therapy (OPT) and Phonetic Placement Therapy (PPT) are forms of oral sensory-motor treatment for speech disorders
• OPT and PPT are not the same as Non-Speech Oral-Motor Exercise (NSOME)

ORAL PLACEMENT THERAPY (OPT) AND PHONETIC PLACEMENT THERAPY (PPT)

The relatively new term Oral Placement Therapy (OPT) coined by Sara Rosenfeld-Johnson (2009) seems to be an updated version of the historical term Phonetic Placement Therapy (PPT). Both OPT and PPT use touch, movement, and tools (which include hands) to help a client attain actual speech sound production. These techniques are used when “look, listen, and do as I say” methods do not work. For example, graded sizes of Bite Blocks have been effectively used to help clients establish appropriate jaw heights as they simultaneously learn to produce front vowels and various consonant sounds (Sacks, Flipsen, & Neils-Strunjas; Bahr & Rosenfeld-Johnson, 2010; Crary, 1993, p. 224). Progressive Jaw Closure Tubes have been used to teach appropriate jaw heights and lip-rounding for back vowels as clients simultaneously learn to produce these speech sounds.

Van Riper, “a founding father of modern speech-language pathology,” described the history and use of PPT in 1954:

For centuries, speech correctionists have used diagrams, applicators, and instruments to ensure appropriate tongue, jaw, and lip placement [for speech sound production].... [These] phonetic placement methods are indispensable tools in the speech correctionist's kit…. Every available device should be used to make the student understand clearly what positions of tongue, jaw, and lips are to be assumed (Van Riper, 1954, pp. 236-238).

In fact, there are many forms of PPT that have been used since the inception of speech-language pathology (Marshalla, 2007, 2012). Currently, OPT and PPT are taught by Sara Rosenfeld-Johnson (2009) and Pamela Marshalla (Marshalla, 2008). However, other forms of this type of treatment include Dynamic Temporal and Tactile Cueing (DTTC), motokinesthetics, palatometry, Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT), and ultrasound imaging (Bahr & Rosenfeld-Johnson, 2010).

OPT AND PPT ARE NOT NSOME (Non-Speech Oral-Motor Exercise)

By definition NSOME (Lof & Watson, 2008, p. 394) is “any technique that does not require the child to produce a speech sound but is used to influence the development of speaking abilities” such as unrelated cheek puffing and tongue wagging. By definition OPT and PPT use touch, movement, and tools (including hands) to attain actual speech sound production. Some OPT and PPT strategies may incorporate oral, vocal, and respiratory exercise as part of treatment (when needed), but each target is a component of actual speech production.

While confused at times in the literature and perhaps in practice, OPT/PPT and NSOME are distinct entities (Bahr & Rosenfeld-Johnson, 2010; Marshalla, 2008). In OPT and PPT, a sequenced and coordinated skill set for speech production is broken down into simpler steps and then combined into the final goal (i.e., the fine-motor function of speech). Similar approaches are used in the fields of occupational and physical therapy. This is a very different process than NSOME which addresses general muscle function (if properly applied) but not speech production.

NSOME has a place in treatment. Across the literature, there seems to be general agreement that NSOME is useful for individuals with muscle function disorders (e.g., those with Down syndrome, cerebral palsy, Parkinson’s disease, etc.) in improving overall muscle function. These individuals have muscle weakness and movement problems throughout the body, and “what you see in the body is what you get in the mouth” (Overland & Merkel-Walsh, 2013, p. 73). When NSOME is used to improve general muscle function, it must be carefully chosen and systematically applied. For example, Ruscello (2008b, p. 294) stated that “there is…a small subset of clients [with velopharyngeal insufficiency] who may improve with treatment using muscle rehabilitation procedures that are task specific to speech.”

Ruscello (2008a, p. 386) also said, “It should be noted that childhood speech disorders caused by neuromuscular deficits…need to be treated accordingly.” In their survey, Lof and Watson (2008, p. 396) found that speech-language pathologists primarily used NSOMEs with children who exhibited motor speech disorders. With the exception of Childhood Apraxia of Speech, children with motor speech disorders usually have generalized muscle function problems.

While McCauley, Strand, Lof, Schooling, and Frymark (2009, p. 343) found “insufficient evidence to support or refute the use of OMEs [oral motor exercises] to produce effects on speech,” researcher Christopher Moore and his colleagues have repeatedly demonstrated (via electromyography) that the neural mechanisms and subsequent motor plans/gestures for speech and non-speech activities are different from one another (Bahr & Banford, 2012). Therefore, NSOME alone is unlikely to improve speech unless it is used with actual speech production techniques. This concept is consistent with OPT and PPT which work on actual speech production through task analysis and successive approximations when properly applied.

THE IMPORTANCE OF WORKING WITH A TRAINED PROFESSIONAL

When selecting appropriate speech treatment for an individual, it is important to be educated about the treatment whether you are a family member or a professional. The treatment needs to be evidence-based, and the therapist supplying the treatment must be properly trained.

Family members can look for professionals specifically trained in OPT and PPT. While it would be ideal if these techniques were taught at the undergraduate and graduate levels, most of this training occurs at the post-graduate level (Bahr & Banford, 2012). So, family members can look for speech-language pathologists trained in DTTC, motokinesthetics, OPT, PPT, PROMPT, ultrasound imaging for speech, palatometry, and similar “hands-on” treatments.

In thinking back to Dr. Rao’s 2011 statement: “EBP is not about identifying the one best approach – it is about deciding which among the many acceptable options is likely to work best for a particular individual.” Both OPT and PPT are viable options for speech treatment when properly implemented. Forms of PPT been used since the inception of speech-language pathology practice.

REFERENCES

American Speech-Language-Hearing Association. (2005). Evidence-based practice in communication disorders [Position Statement]. Available from www.asha.org.

Bahr, D. (2008, Jan.). A topical bibliography on oral motor assessment and treatment. Oral Motor Institute, 2(1). Available from www.oralmotorinstitute.org.

Bahr, D. (2011, Sept.). The oral motor debate - Part I: Understanding the problem. Oral Motor Institute, 3(1). Available from www.oralmotorinstitute.org.

Bahr, D. (2011, Nov.). The oral motor debate – Part II: Exploring terminology and practice patterns. Oral Motor Institute, 3(2). Available from www.oralmotorinstitute.org.

Bahr, D., & Banford, R. J. (2012, Jan.). The oral motor debate – Part III: Exploring research and training needs/ideas. Oral Motor Institute, 4(1). Available from www.oralmotorinstitute.org.

Bahr, D., & Rosenfeld-Johnson, S. (2010, Feb.). Treatment of children with speech oral placement disorders (OPDs): A paradigm emerges. Communication Disorders Quarterly, 31, 131-138.

Crary, M. A. (1993). Developmental motor speech disorders. San Diego, CA: Singular.

Lof, G. L., & Watson, M. (2008, Jul.). A nationwide survey of nonspeech oral motor exercise use: Implications for evidence-based practice. Language, Speech, and Hearing Services in Schools, 39, 392-407.

Marshalla, P. (2007, Sept.). Oral motor techniques are not new. Oral Motor Institute, 1(1). Available from www.oralmotorinstitute.org.

Marshalla, P. (2008, Apr.). Oral motor treatment vs. non-speech oral motor exercises. Oral Motor Institute, 2(2). Available from www.oralmotorinstitute.org.

Marshalla, P. (2012, Apr.). Horns, whistles, bite blocks, and straws: A review of tools/objects used in articulation therapy by Van Riper and other traditional therapists. Oral Motor Institute, 4(2). Available from www.oralmotorinstitute.org.

McCauley, R. J., Strand, E., Lof, G. L., Schooling, T., & Frymark, T. (2009, Nov.). Evidence-Based systematic review: Effects of nonspeech oral motor exercise on speech. American Journal of Speech-Language Pathology, 18(4), 343-360.

Oral Motor Institute (n.d.). Home page: Mission statement. Available from www.oralmotorinstitute.org.

Overland, L. L., & Merkel-Walsh, R. (2013). A sensory motor approach to feeding. Charleston, SC: TalkTools.

Rao, P. R. (2011, Jun. 7). Evidence-Based practice: The coin of the realm in CSD. The ASHA Leader, 16(7), 7.

Rosenfeld-Johnson, S. (2009). Oral placement therapy for speech clarity and feeding (rev. 4^th ed.). Tucson, AZ: Innovative Therapists International.

Ruscello, D. M. (2008a). Nonspeech oral motor treatment issues related to children with developmental speech sound disorders. Language, Speech, and Hearing Services in Schools, 39, 381-391.

Ruscello, D. M. (2008b). An examination of nonspeech oral motor exercises for children with velopharyngeal inadequacy. Seminars in Speech and Language, 29, 294-303.

Sacks, S., Flipsen, P., & Neils-Strunjas, J. (2013, Oct.). Effectiveness of systematic articulation program accessing computers (SATPAC) approach to remediate dentalized and interdental /s, z/: A preliminary study. Perceptual and Motor Skills, 117(2). 559-577.

Van Riper, C. (1954). Speech correction: Principles and methods. Englewood Cliffs: Prentice-Hall.

AUTHORS

Robyn Merkel-Walsh is a speech pathologist who is employed by the Ridgefield Board of Education, TalkTools, as well as her own practice. Robyn is an international lecturer who specializes in muscle and motor based speech disorders, feeding, and orofacial-myofunctional disorders. She is the co-author of A Sensory Motor Approach to Feeding (2013) and the Oral Placement to Speech Kit (2011). She is the author of the 2002 SMILE (SysteMatic Intervention for Lingual Elevation) program and has published many popular articles.

Diane Bahr is co-owner of Ages and Stages®, LLC (Resources for Feeding, Speech, and Mouth Function) and the author of Oral Motor Assessment and Treatment: Ages and Stages (2001) and Nobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development (2010). She has taught at both the undergraduate and graduate levels and is currently an international speaker on the topics of feeding, motor speech, and mouth function. She has also written extensively on these topics.

Both authors are experienced master clinicians and Board Members for the all-volunteer Oral Motor Institute study group.