This is a repost from Dean Trout’s Little Shop of SLP, with permission from the author.

Upon reaching out to her for permission, here's what Dean wrote: "I found TalkTools to be great for oral awareness and teaching segmentation of articulators!"

Dean Trout worked for 31 years as a Speech Therapist in the public school system and for 4 years in her own speech clinic. She started 2 Gals Speech Products, LLC in 2007, spoke at several speech conferences and have been published in the ASHA Leader. Today she creates tangible things that she sells in her Etsy store as well as digital downloads in her TpT store. "For you who are new to the field of SLP, I want to give tips and tricks to make your therapy more effective. ... For you more mature SLPs I want you to feel comfortable with technology and social media." 

April 10, 2017

I have often felt baffled as to why kids cannot produce /k/ when developmentally we make posterior sounds before anterior. Think about it, a baby’s first sounds are goo-goo and ga-ga, so isn’t /k/ just a naturally developing response? It makes me go, hmmm. Luckily there are several ways to go about teaching this sound. These tips are not in any particular order, so don’t think Tip #1 is the best. All these tips have been used successfully by several of my colleagues and me.  Please remember what works with one child does not always work with another. We are simply sharing some ideas of things to try.

This tip is not EBP and I am not trying to pass it off as such.  I am just sharing an out of the box idea for when all else has failed.  In my many years of practice, I have found that the major reason a child cannot imitate a sound from our model and demonstration is simply that they don’t understand what we are telling them to do. They just don’t “get it.” It also seems that they more often than not just don’t get it when we try to show and explain how to do those sounds that are made in the back of our mouths: /k/, /g/, /r/. So to help them “get it” I try to relate the sound to something to which they are familiar. Most all of us have eaten popcorn and don’t we all, at times, get a husk caught on the back of our tongue and have to clear it out? That is what I use to help them understand what I mean by the back of the mouth or back of the tongue, etc. Every child I have had in therapy can show me with 100% accuracy where the front and back of the mouth is located on a drawing and can point to the front and back of their own mouths, but yet cannot put their own tongues there. To teach them how to find and lift the back of their tongues, we practice that horrible hacky-growly guttural sound we make when clearing out the popcorn. We do this until I feel they fully understand what I mean when I say use the back of your tongue. Once they “get it” you can shape it into a beautiful /k/ in isolation and begin your regular therapy. If they forget to get their tongue up when drilling syllables or words, just cue with “clear out the popcorn.”

If you really want to be the fun “speech teacher” why not bring some popcorn to eat in therapy? Just check for food allergies first ;)

TIP#2 Cereal

You can also get correct tongue positioning for /k/ using cereal-Cheerios or Fruit Loops. This approach is taught by Sara Rosenfeld-Johnson in her Talk Tools program. Basically, what you do is place the cereal behind the bottom front teeth and have the child place the tip of his tongue in the cereal hole and hold it there to keep the tip down while making the /k/ using the back of the tongue. This technique is explained in detail in the Talk Tools program. Here is the link to the website. http://www.talktools.com/ I highly recommend you learn how to implement this technique because it is effective. It is great for kids who front the back sounds and need the tactile cueing.

TIP #3 Tactile Cues—Holding the Tip and Blade

For years I have had kids to use their own finger to hold the tongue tip down to get the correct position for /k/ when they were substituting /t/ for/k/. Many times they will have to not just hold the tip but the tongue blade as well. You can start out with them holding only the tip down while they say /k/, but if they start making the /k/ with the blade of their tongue mid palate you will have to have them hold more of the tongue down and push the tongue further back in their mouths. This has been exceptionally effective at achieving a good /k/ sound. Many people do not like this approach, but if it works then I say use it. I have had some kids who have had to use their finger to hold their tongue down not only in isolation but through syllable and even a few into words (gasp)! However, never fear, I have never had a kid graduate from speech therapy and still have their finger in their mouth!! I never ask them to quit using their finger. They eventually get tired of using it and stop on their own. Don’t you think we sometimes worry too much about the little things?

When implementing this strategy if you are the one holding the child’s tongue via your own gloved hand, finger cot, or tongue depressor be careful of a hyper gag reflex. If you find a child with a hyper gag, you have two choices: 1) desensitize the gag reflex or 2) don’t use this approach. If the child can tolerate you inside his mouth a nice little tip is to use flavored toothpaste on a dental swab. It is just less invasive tasting.

TIP# 4 Use Gravity

Some children need a little more help learning to elevate the back of their tongue, and gravity helps! There are suggestions to have the children let their head lean over the back of their chair or have them lie on the floor. Personally, I have had no success with using the chair technique. I have had success doing therapy while the child is lying on his/her back on the floor. Initially, I just have the child lie on his back on the floor and do some deep breathing exercises to help him relax. I will sometimes lay a book on his stomach for this. They can see the book rise and fall as they breathe. After the child looks relaxed and at ease with lying on the floor, I begin therapy using the other techniques explained in this article. The one that seems to work the best is using tactile cues. I will start with a tongue blade and gently “push” the tongue tip down toward the back of the mouth. If this doesn’t work, I try having the child “cough” really hard, (similar to the clearing of the throat.) Usually, this combination of techniques works within one to two sessions, and we can go back to sitting in our chairs for therapy.

TIP#5 Getting Tongue Retraction

You cannot produce a /k/ without your tongue retracting back into the mouth. To achieve a tongue retraction response, stimulate midline of the tongue from anterior to posterior with a tongue depressor or your gloved finger. Pam Marshalla explains this very well on the websitehttps://pammarshalla.com/stimulating-tongue-back-elevation-for-k-and-g/

I suppose this sums up every tip and trick we have up our sleeves. Hopefully, this has affirmed that what you’re doing is right or maybe even got you to thinking it is ok to try something off the wall in therapy.  I am all for Evidence-Based Practice but sometimes when all else has failed you must try something unique.  It just might work for this particular student.  

I will not discuss or debate EPB, so no need to leave heated comments. 

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.

This case study was originally posted in Advance for Speech & Hearing on November 14, 2016. Retrieved from http://www.advanceweb.com/

Author: Gabrielle Zimmer, MS, CCC-SLP

Brain Stem Stroke: A Case Study

Rebuilding communication one subsystem at a time.

Where do you start when a client understands everything that is said but has no way to communicate back to you? He cannot speak, gesture or write. How can you improve his quality of life?

As speech-language pathologists in the outpatient department at Kessler Institute for Rehabilitation, we frequently encounter challenging situations and provide treatment for medically complex adults who have suffered acquired and traumatic brain injuries (TBIs). To maximize each client’s potential, collaboration with an interdisciplinary team, including physicians, therapists and other specialists, is crucial. The implementation of a variety of treatment approaches based on the individual needs of the client is also critical.

An example of a complex case in which collaboration was necessary is the case of Ben, a 38-year-old male who began feeling right upper extremity twitching and slurred speech. This evolved and progressed and an MRI revealed a severe brainstem stroke. Ben was ultimately diagnosed with Locked-In Syndrome. He was unable to move any part of his body, although his receptive and expressive language and cognition remained entirely intact. He remembers hearing and understanding all that was being said at his bedside, but he was unable to express himself in any way with the exception of eye blinking. Ben recounted his inability to make requests such as to turn on the fan, feed him ice chips or scratch an itch.

Familiar Voice

Ben completed acute inpatient rehabilitation at Kessler and progressed to a state in which he could move his neck and to a small degree his mouth, lips and tongue. By using the eye gaze access feature of a high technology augmentative and alternative communication (AAC) speech generating device, Ben was able to demonstrate to his family members for the first time since his stroke that “he was in there.” This allowed him to communicate his wants and needs, ask questions and express concerns. He was an excellent candidate for an AAC device, but strived to speak in his own voice. Ben achieved his swallowing goals and was beginning to target phonation when he was discharged from inpatient therapy and transitioned to my care in the outpatient department.

When Ben started outpatient therapy, he had significantly reduced breath support, severely reduced tongue, lip, cheek and jaw movement, and was aphonic and unintelligible. He had difficulty changing his facial expressions to convey emotion and was unable to manage his saliva. He required 24/7 supervision and assistance and was unable to verbally communicate his basic wants and needs. Initially, I trialed traditional approaches to improve articulatory movement as well as voice exercises but quickly felt like we were hitting a wall. I felt it was necessary to break down and target each speech subsystem to maximize his abilities.

Tactile Approach

I sought an evaluation from an otolaryngologist who specializes in voice disorders to examine the integrity of his vocal cord movement which proved to be within normal limits. The difficulty appeared to be with the coordination of inhalation and exhalation for productive voicing as well as a resonance disorder due to limited velar movement. Volitional diaphragmatic breathing was challenging and most of his air was lost through his nasal cavity.

Knowing that his vocal cords were functioning properly was promising for the goal of achieving consistent voicing going forward. We used a spirometer for visual feedback and to target consistent volitional inhalation and exhalation for speech. Additionally, we consulted with a prosthodontist to further examine Ben’s palatal movement and to assess his candidacy for prosthesis. Ben was deemed a viable candidate and use of the palatal lift helped improve voicing and increased his volume. Now that voicing was becoming more consistent and breath support was improving, our goals shifted to articulatory movement and intelligibility.

Initially, Ben attempted to mouth single letters and words for lip reading. With such poor movement of his cheeks, lips and tongue, success was inconsistent and extremely frustrating for both Ben and his family. A tactile approach was deemed necessary for this case. I implemented two excellent therapeutic interventions – the Beckman Oral Motor Protocol and oral placement therapy with Talk Tools. The Beckman Oral Motor Protocol provided assisted movement to activate muscle contraction and movement against resistance to build strength and increased control of movement for the lips, cheeks, jaw, and tongue.

This was done in conjunction with a variety of hierarchical oral placement therapy techniques with Talk Tools, such as the jaw grading bite block, bubble blowing, horn blowing, velar grading and straw hierarchies, among others.

Improved Articulatory Movement

The initial tactile-kinesthetic feedback was crucial and contributed to improved articulatory movement. All oral placement tasks were paired with functional speech tasks. Ben began to increase intelligibility starting at the single word level, progressed to the basic phrase level and subsequently advanced to the sentence level. In addition, although Ben was tolerating a regular solid diet with thin liquids, he had self-established habitual patterns to compensate for his limited tongue and lip movement. The treatment approaches that were initially sought to improve his articulatory movement for speech simultaneously improved his feeding and swallowing function as well.

Ben progressed from an aphonic state to demonstrating increasingly controlled respiration for consistent phonation at the conversation level. Focus shifted to improve volume, pitch and vocal quality. His articulatory movement was severely limited, and he improved to the point where he produced intelligible sentences. Carryover was targeted outside of the speech therapy treatment room with collaboration between his physical and occupational therapists. He targeted speech goals to maintain phonation and intelligibility in different positions such as standing upright, lying on his back and during facilitated movement.

This same person who initially relied on an AAC device was now able to gradually participate in conversation using his own voice and his personality emerged. I began to learn about Ben’s interests, such as his skill at trivia, opinions on television shows and sarcastic sense of humor. He achieved major milestones, which included his abilities to participate and self-advocate in doctors’ appointments, hold conversations with his wife out to dinner and contribute to group conversation. His independence increased and required less caregiver support as he could call for help if needed.

Maximizing Abilities

In a complex case like Ben, utilizing a variety of treatment approaches was crucial to his progress and success. It is important to create individualized treatment programs that are comprehensive and functional for the client. The key to maximizing the client’s abilities is maintenance of well-rounded continuing education, implementation of strong evidence-based practice, collaboration within an interdisciplinary rehabilitation team and daily completion of a home exercise program for carryover outside of the therapy setting. This is in combination with time and dedication from the client and their support system. Ben said it best, “You can sit back and wait for a miracle, or you can make one happen. Let’s make a miracle!”

Resources

1: Beckman, D.A., (1994, Rev. 2010). Beckman Oral Motor Assessment and Intervention. Published by Beckman & Associates, Inc., 620 N Wymore Rd, Suite 230, Maitland, Florida 32751-4253. www.beckmanoralmotor.com

2: Rosenfeld-Johnson, S. (2014). A Therapist Guide to Rehabilitative Feeding and Speech Techniques for Teens and Adults: TalkTools, Charleston, SC.
Gabrielle Zimmer, MS, CCC-SLP is a speech-language pathologist and clinical specialist at Kessler Institute for Rehabilitation in West Orange, New Jersey.

Top-ranked by U.S.News & World Report for the 23rd consecutive year, Kessler Institute is the only rehabilitation hospital in New Jersey to be named to the prestigious list of “America’s Best Hospitals” and is the leading center of its kind in the East.

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.

This presentation was made at the 2015 annual ASHA Convention, Session #1080.

Abstract:

Practicing Speech-Language Pathologists report that many clients demonstrate limited or excessive up-and-down jaw movements during communication as compared to their typically developing peers.  The results of this retrospective study suggest that atypical jaw skills are related to deficits in speech clarity in clients diagnosed with multiple articulation disorder and dysarthria.

Summary:

Practicing Speech-Language Pathologists report that many clients, with diagnosed multiple articulation disorders, demonstrate limited or excessive up-and-down jaw movements during communication as compared to their typically developing peers.  The focus of this retrospective study was to determine if children and adults, diagnosed with multiple articulation disorders, were using the jaw heights needed to allow the tongue and lips to move independently for consonant and vowel productions on the conversational level. “Individual differences in jaw movement are real and often large; and the jaw is, in a real sense a primary articulator, controlling tongue height for an open vowel (Gay, 1974).   Video clips of clients’ jaw mobility during conversational speech, before and after bite block invention, will be shown throughout this presentation.

These same clients were often able to produce the targeted speech sound(s) on the word level in a standardized articulation test but could not produce these same phonemes consistently on the conversational level.  The sentence, “As the rate and complexity of the statement increases, the intelligibility decreases,” is  found in many SLP’s reports to describe this breakdown in speech clarity.

More than forty years ago Edward Mysak suggested that if articulatory efforts are disrupted by excessive orofacial activities, as observed in many children with cerebral palsy, therapeutic techniques designed to restrain these compounding events must be administered to facilitate speech improvement (Mysak 1968).  Ten years later James Dworkin proposed a causal relationship between the articulatory imprecision exhibited by certain school-age children and their co-occuring interruptive, hyperactive or hypoactive mandibular movement patterns” (Dworkin 1978).  Clinical focus was then shifted to a treatment method that could measure the degree of jaw activity.  Acrylic bite blocks of varying heights were positioned between the upper and lower central incisor teeth. The children were required to bite down gently on a given block, so as to stabilize the mandible.  Substantial improvements in speech proficiency and intelligibility were obtained in all of the children studied in a relatively short period of time (Dworkin 1978). Kent and Lybolt (1982), Rosenbek and LaPointe (1985), Netsell (1985), and Dworkin (1991) all discussed the potential diagnostic and therapeutic value of bite block use in the differential diagnosis and treatment of dysarthric patients.

Other studies support the idea that SLPs need to take a closer look at how jaw grading is related to speech production.  A 2000 study reported, “precise control of jaw movements precedes lip-control, control over jaw and lip coupling, and independence of upper- and lower-lip movement” and “the present results might be taken to suggest that limited mandibular control in early speech is a negative prognostic factor for later speech motor delays” (Green, 2000).  Research into myofunctional disorders identified the relationship between the tongue and jaw dissociation for speech (Meyer, 2000).

In 2003, the following comments were made in a response to the Green, Moore, and Reilly article (Green, 2002) in reference “to the select populations of children and adults with developmental or neurogenic articulation disorders who exhibit mandibular dyscontrol. On the basis of our present work with such patients and a reinforcing clinical literature database, we suggest that the mandible may play a leading role not only in normal articulatory development but also in the origin and persistence of certain abnormal speech behaviors (Dworkin, 2003).

In our present study the charts of several different clinical populations were examined.  Subjects were chosen based upon the examiner’s comment that limited or excessive mandibular activity was observed during conversational speech.  A video-based movement tracking system had been used to chart the jaw range of motion in connected speech for each of the subjects. In the initial evaluation both the Goldman-Fristoe Test of Articulation (G-FTA-2) and the DCOMT (Dworkin-Culatta Oral Mechanism Examination and Treatment System) had been administered.  Based on the results of these inventories, all subjects had been diagnosed with a multiple articulation disorder and dysarthria. Client’s with the diagnosis of motor speech disorders such as Childhood Apraxia of Speech (CAS) or Acquired Apraxia of Speech (AOS) were not included in this study.

Bite blocks representing the following jaw heights were used to assess skills at the high jaw placement (m, b, p, f, v, n, s, z, ∫, t∫, r, vocalic r, I, I, Ʋ, u – teeth almost touching), medium jaw placement (θ, ð, l, t, d,Λ, ɛ, ə, ɔ - teeth slightly more open) and low jaw placement (g, k, h,ɑ, æ - teeth even slightly more open) (Marshalla, 1982).

Prior to data collection, these same bite blocks were used to assess the jaw skills of twenty-five randomly selected children and adults between the ages of 2.5 and 50 years whose speech clarity was considered to be within normal limits as reported by an independent judge. The task was to use the back molars to bite-and-hold the jaw still for fifteen (15) seconds, at each bite block height, while an isometric pull was introduced.  Each of these twenty-five individuals was able to perform the bite block task without error.  The SRJ Therapies client charts, spanning a period of 12 years, were then examined.  The following clients qualified for the study: 1) Down syndrome: 230, 2) Cerebral Palsy: 24, 3) Benign Hypotonia: 180, 4) Other syndromes characterized by hypotonia: 33, and 5) Clients with no medical diagnosis who had been enrolled in speech therapy for a minimum of four years  and who had not demonstrated significant improvement: 42.  The clients ranged in age from 2.5 years to 47 years.

The results of this retrospective study are remarkable in that only 8% of the 509  client-subjects were able to perform the bite block task without error; 92%  could not complete the task. These results suggest that jaw skills are related to deficits in speech clarity in clients with the diagnosis of a muscle-based multiple articulation disorder and dysarthria.  Because this was a retrospective study the limitations are clear. The next step would be large sample, double-blind studies that would definitively address the use of bite blocks for diagnosis and treatment of clients with muscle-based speech clarity disorders.  

Learner Outcomes: 

1. Participants will be able to identify client’s with atypical jaw mobility during conversational speech.

2. Participants will understand the possible relationship between atypical jaw mobility and dysarthria

3. Participants will be able to use bite blocks to assess jaw skills in clients with the diagnosis of dysarthria

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