moderated by: amy hansen, m.a., ccc-slp, managing...

7/7/2011

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Updating Evidence Against NSOME for Speech Sound Production

PPresenter:Gregory Lof, Ph.D., CCC-SLP

Moderated by:

Amy Hansen, M.A., CCC-SLP, Managing Editor, SpeechPathology.com

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Updating Evidence Against Updating Evidence Against Nonspeech Oral Motor Exercises Nonspeech Oral Motor Exercises

(NSOME) for Speech Sound (NSOME) for Speech Sound ProductionsProductions

Gregory L. Lof, PhD, CCC-SLPDepartment Chair/Professor

July, 2011

Boston, MA

A special thanks to…

Dr Maggie WatsonDr. Maggie WatsonUniversity of Wisconsin-

Stevens Point

Why not Nonspeech Oral Motor Exercises (NSOME) to change(NSOME) to change

speech sound productions?

• Do SLPs routinely use oral motor exercises?

• Why do SLPs use them?

Are SLPs using Evidence Based

Practice?

Some Practical Questions About Oral Motor Exercises

• What exercises do SLPs use?• What proof do SLPs have that they

are effective in bringing about changes in speech-sound productions?

Practice

Outline of Talk

Trends (using survey data)

Logical Reasons

Not to Use

Outline of Talk

Not to Use

Oral Motor

Exercises

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Theoretical Reasons

Not to Use

Outline of Talk

Not to Use

Oral Motor

Exercises

Evidence Why

Not to Use

Outline of Talk

Not to Use

Oral Motor

Exercises

Nonspeech Oral

Definitions

p

Motor Exercises

Any technique that does not require the child to produce

Nonspeech Oral Motor Exercises Defined

q pa speech sound but is used

to influence the development of speaking abilities.

Lof & Watson (2008)

A collection of nonspeech methods and procedures that are purported

to influence tongue lip and jaw


to influence tongue, lip, and jaw resting postures, increase strength,

improve muscle tone, facilitate range of motion, and develop

muscle control.(Ruscello, 2008)

Oral-motor exercises (OMEs) are nonspeech activities that involve sensory stimulation to or

actions of the lips, jaw, tongue, soft palate, larynx, and respiratory muscles which are intended to


and respiratory muscles which are intended to influence the physiologic underpinnings of the

oropharyngeal mechanism and thus improve its functions. They include active muscle exercise,

muscle stretching, passive exercise, and sensory stimulation.

McCauley, Strand, Lof, et al. (2009)

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Note that I will be talking about procedures and techniques that


do not use speech.

NSOMENSOME

Not about: Not about: feeding, swallowing, droolingfeeding, swallowing, drooling


g g gg g g

S p e e c h

Do SLPs Use NSOME?

Nationwide Survey

Do SLPs Use NSOME?

Lof & Watson (2008)

Nationwide survey of 537 SLPs

85% use NSOME to

Do SLPs Use NSOME?

85% use NSOME to change speech sound

productions

Lof & Watson (2008)

Nationwide survey of 535 SLPs in Canada

Do SLPs Use NSOME?

Hodge, Salonka, & Kollias, (2005)

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Nationwide survey of 535 SLPs in Canada

85% use NSOME to

Do SLPs Use NSOME?

85% use NSOME to change speech sound

productions!

Hodge, Salonka, & Kollias, (2005)

Survey of SLPs in Kentucky

Do SLPs Use NSOME?

Approximately 79% use

Cima, Mahanna-Boden, Brown, & Cranfill (ASHA, 2009)

79% use NSOME to change speech sound productions

Survey of SLPs in South Carolina

Do SLPs Use NSOME?

Approximately 81% believe

Lemmon, Harrison, Woods-McKnight, Bonnette, & Jackson, (ASHA, 2010)

NSOME are at least somewhat effective in bringing about speech sound improvements

Do SLPs Use NSOME?

How did clinicians learn How did clinicians learn about NSOME?about NSOME?

Lof & Watson (2008)

87% from CE offerings, workshops, In-services

87%

Do SLPs Use NSOME?

How did clinicians learn How did clinicians learn about NSOME?about NSOME?

25% f i it

Watson & Lof (2009)

25% of university professors who teach speech

sound disorders teach NSOME

75%

Rank order of most frequently used exercises:Rank order of most frequently used exercises:

1. Blowing 6. Tongue-to-nose-to chin

Do SLPs Use NSOME?

2. Tongue push-ups

3. Pucker-smile

4. Tongue wags

5. Big smile

7. Cheek puffing

8. Blowing kisses

9. Tongue curling

Lof & Watson (2008)

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Rank order of most frequently identified Rank order of most frequently identified “benefits” of these exercises:“benefits” of these exercises:

Do SLPs Use NSOME?

1. Tongue elevation

2. Awareness of articulators

3. Tongue strength

4. Lip strength

5. Lateral tongue movements

6. Jaw stabilization

7. Lip/tongue protrusion

8. Drooling control

9. VP competence

10.Sucking ability

Lof & Watson (2008)

Clinicians Clinicians USUALLYUSUALLY use these use these exercises for children with…exercises for children with…

Do SLPs Use NSOME?

1. Dysarthria

2. Childhood Apraxia of Speech (CAS)

3. Structural anomalies (e.g., clefts)

4. Down syndrome

Lof & Watson (2008)

Do SLPs Use NSOME?

Clinicians Clinicians FREQUENTLYFREQUENTLY use these use these exercises for children with…exercises for children with…

1. In early intervention

2. Late talkers

3. Phonologically impaired

4. Hearing impaired

5. Functional misarticulatorsLof & Watson (2008)

Evidence-Based Practice

• The conscientious, explicit, and unbiased use of current best research results in making decisions about the care of i di id l li t


individual clients.

• Treatment decisions should be administered in practice only when there is a justified (evidence-based) expectation of benefit.

Sackett et al., (1996)

Research Evidence


EBP

Clinical Experience Client Values

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EBP is the integration of best research evidence along with clinical expertise

and the client values


and the client values

EBP uses the best evidence available, in consultation with the client or parents to

decide upon the options that suits the client best.

The Purpose of EBP

P t


Promotethe adoption of effective interventions

The Purpose of EBP


Delaythe adoption of unproved interventions

The Purpose of EBP


Preventthe adoption of ineffective interventions


Most of the evidence th ffi f

Levels of Evidence from Studies

on the efficacy of NSOME is on the somewhat weaker

side, but…



LEVEL Ib: STRONG Well designed randomized controlled study

LEVEL Ia: STRONGEST Well-designed meta-analysis of >1 RCT

LEVEL Ib: STRONG Well-designed randomized controlled study

LEVEL IIa: MODERATE Well-designed controlled study without randomization

LEVEL IIb: MODERATE Well-designed quasi-experimental study

LEVEL IV: WEAK Opinion of authorities, based on clinical experience

LEVEL III: LIMITED Nonexperimental studies (i.e., correlational and case studies)

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Dollaghan (2004, 2007) reminds clinicians that when using the EBP paradigm, valid and reliable evidence needs to be given more credence than intuition anecdote and


more credence than intuition, anecdote and expert authority.

While opinions and clinician's own clinical experiences can be useful, they

can also be biased and even wrong!

Finn, Bothe, & Bramlett (2005)


Science and Pseudoscience in Communication Disorders: Criteria and Applications

Science


vs. Pseudoscience


Science:Science:


Information is developed through research and other empirically based activities.


Pseudoscience:Pseudoscience:“A pretend or spurious science; a


p p ;collection of related beliefs about the world mistakenly regarded as being

based on scientific method or as having the status that scientific truths

now have.”Finn, Bothe, & Bramlett (2005)

Quackery and Pseudoscience can go together

Quackery is anything


Quackery is anything involving over-promotion

in a clinical field


Includes questionable ideas and questionable products and services, regardless of the sincerity of the promoters

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You know it is


it is Pseudoscience

when…


Disconfirming evidence

is ignored and practice

You know it is …

You know it is pseudoscience when…

is ignored and practice

continues even though

the evidence is clear.


The only “evidence” is anecdotal,

supported with

You know it is …


supported with statements from

personal experience

(testimonials)Finn, Bothe, & Bramlett (2005)

Inadequate

You know it is …


evidence is

accepted


The printed materials

You know it is …


are not peer

reviewedFinn, Bothe, & Bramlett (2005)

Grandiose outcomes are proclaimed

You know it is …



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Muttiah, Georges, & Brackenbury

(2011)


Qualitative Study:Interviews with

• 11 clinicians who use NSOME

• 11 researchers who are against their use

Oral Motor Tasks…

This is the logical part

Tongue Push-UpsObjective: to strengthen tongue Procedure: child holds up an M&M, cheerio, etc. on upper ridge just

behind teeth (not on teeth) and pushes up with tongue.

Some Exercises From the Web:http://www.widesmiles.org/cleftlinks/WS-563.html

Tongue PopsObjective: To strengthen tongue Procedure: Suck tongue up on the top of the mouth, pull it back and

release it, making a popping sound.Pointy TongueObjective: To increase tongue movement and coordinationProcedure: Protrude tongue and point it at the tip.

WhistleObjective: To increase lip strengthProcedure: Have child pucker lips and blow attempting to whistle.Fish Mouth

Some Exercises From the Web:http://www.widesmiles.org/cleftlinks/WS-563.html

Objective: To increase oral-motor strengthProcedure: Pucker lips and suck cheeks in to make a "fish-face"Pucker-SmileObjective: To increase oral-motor coordinationProcedure: Have child close mouth with back teeth together. Have

child pucker lips (while keeping back teeth together). Once mastered, have child alternate a pucker with a smile.

Some questions to ask yourself as you

Do NSOME make logical sense?

yourself as you evaluate these tasks…

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There is evidence that shows that NSOME doshows that NSOME do

not work. Why is it being ignored?


There is NO evidence that shows thatthat shows that

NSOME do work. Why is this being ignored?


Why are the materials and procedures used inand procedures used in NSOME not brought up

for peer-review scrutiny?


Why are the materials and proceduresand procedures promoted only in

self-published materials and on websites?


Why do these websites h ti fhave a section for

“testimonials” but not for “research”?


How could one procedure work toprocedure work to remediate so many disparate types of

problems?

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For example, look at some of the catalogs

that promote NSOME…

From a Catalog:

Grandiose outcomes are proclaimed

If i i d

Remember Pseudoscience

If it is too good to be true, it probably is not true!



What is the monetary benefits to the

promoters of NSOME?

Are NSOME Logical?

?

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Now For the Theory Part

Part-whole training and transfer

Strengthening the structures

Why Exercises are THOUGHT to be Effective


Relevancy to the act of speaking

Task specificity

Warm-up/Awareness/Metamouth

Part-Whole Training and Transfer


Premise:

If we teach smaller parts of aIf we teach smaller parts of a

speech gesture, it will help in

the acquisition of the whole

speech gesture.


However, it has been shown that…

Tasks that comprise highly organized or g y gintegrated parts will not be enhanced by learning of the constituent parts; rather,

training on parts of these organized behaviors may diminish learning.


What this means...

Highly organized tasks require

l i f th i f tilearning of the information

processing demands as well as

learning time sharing and other

intercomponent skills.

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“Fractionating a behavior that is composed of interrelated parts i t lik l t id l tis not likely to provide relevant information for the appropriate

development of neural substrates.”

Forrest (2002)


It is the breaking the whole task

i t llinto small, meaningless

subtasks that will not be effective.


An example of this was recently reported to me by a student clinician who was assigned to a practicum

with a school SLP. The student described how they had been extensively drilling a child to use a “lowerhad been extensively drilling a child to use a lower

lip biting” maneuver with the ultimate goal of evoking the /f/ sound. During the many sessions with the child, they never worked on the actual

speech sound, instead only practiced the isolated exaggerated lingual-dental gesture.


“Training the Whole”Ingram & Ingram (2001)

“Whole-Word Phonology and Templates”

Velleman & Vihman (2002)


Summary– Learning of tasks with interdependent parts

is not improved by decomposition.– Fractionation and simplification of a task do

not yield any improvements in learning a target behavior.

– Do not break things into small subtasks because there probably will be no transfer of that skill to the whole.






Task specificity


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Increase in Strength

Do SLPs USE NSOME?

Rank order of most frequently identified

“benefits” of these exercises:

1. Tongue elevation


3. Tongue strength

4. Lip strength




8. Drooling control

9. VP competence

10.Sucking ability

Lof & Watson (2008)

Four Questions about Strength:

1. Is strength needed for speech?


2. Will NSOME actually increase strength?

3. How is strength adequately measured?

4. Do children with speech sound disorders

have weakness?

Question Question 11

Is strength needed


Is strength needed

for speech?

Strength needs for speech are VERY low

– Lip muscle force for speaking is only about 10-

20% of the maximal capabilities of lip force.


p p

– The jaw uses only about 11- 15% of available

amount of force that can be produced.

– Activation of the laryngeal muscles is between

10% - 20% of maximum.


In other words, the speaking strength

d d t h l t


needs do not come anywhere close to

the maximum strength abilities of the

articulators.

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“…only a fraction of maximum tongue force is

used in speech production, and such


used in speech production, and such

strength tasks are not representative of the

tongue's role during typical speaking. As a

result, caution should be taken when directly

associating tongue strength to speech…”

Wenke, Goozee, Murdoch, & LaPointe (2006)


Children need agility and fine

ti l t t


articulatory movements

Strength needs for speech are VERY lowChildren need agility and fine articulatory movements

–Need agility, not strength


Need agility, not strength

–NSOME encourages gross and exaggerated

ranges of motion, not small, coordinated

movements that are required for talking


– Motor SKILL training induces motor map


g p

reorganization, whereas strength training does

not (Remple et al., 2001).

– Exercise alone (as opposed to skill training) will

not alter motor map organization (Kleim et al.,

2002).


– Different adaptive changes are evoked with


p g

strength training than with skill training (Jensen et

al., 2005).


Will NSOME


Will NSOME

actually strengthen

the articulators?

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A non-speaking example:

Bicep weight training


• Repetitions to failure?• Repetitions to failure?

• Against resistance?

• Increase agility and range of motion?


Bicep weight training


Do people who use NSOME follow this basic strength training paradigm?

Will NSOME actually strengthen the articulators?

Bl i i id i


A Speaking Example: VP Closure

Blowing exercises can aid in

velopharyngeal closure for

other blowing tasks; but this

closure is not maintained for

speaking.


Li l i i


A Tongue Exercise Example with Normal Adults

Lingual exercises using

protrusion and

lateralization, 30 repetitions

a day, 7 days a week, for

9 weeks

Clark, O’Brien, Calleja, & Corrie (2009)


P d d 6% t 26%


A Tongue Exercise Example with Normal Adults

Produced 6% to 26%

increase in strength.

Significant loss of strength

(back to baseline) once

training ended.

Clark, O’Brien, Calleja, & Corrie (2009)



A Swallowing Example

Lingual exercises can strengthen the tongue

and it can have an effect on swallowing.

Robbins, J., Gangnon, R., Theis, S., Kays, S., Hewitt, A., & Hind, J. (2005)

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But it takes A LOT of exercises:

• 8 weeks

• 30 exercises against resistance

A Swallowing Example


• 3 times a day

• Every other day

Strength increased: only ~ 6 kPa or

~ 17% increase in 8 weeks


Lip Strengthening Exercises• 8 7-19 year olds with Myotonic Dystrophy Type 1• Counter balanced design for 32 weeks• Exercised 16 minutes 5 days/week against resistance

Sjögreena, L., Tuliniusb, M., Kiliaridisc, S., & Lohmanderd, A. (2010). The effect of lip strengthening exercises in children and

adolescents with myotonic dystrophy type 1. International Journal of Pediatric Otorhinolaryngology, 74(10), 1126-1134.

• Exercised 16 minutes, 5 days/week against resistance• Results:

• Only 4 improved maximal lip strength• Lip strength did not lead to improved function for

speech, eating, drinking, mobility, or saliva control• Strength was not maintained over time



Only if the standard strength training paradigm is followedtraining paradigm is followed.

But it may not improve function!


How is strength


How is strength

adequately measured?

Measurements of


strength are usually

highly subjective

Measurement of strength is

typically done subjectively


For example, feeling the force of the tongue

pushing against a tongue depressor or against

the cheek

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typically done subjectivelyT t t th li i i l h ld


To assess tongue strength, clinicians commonly hold a

tongue depressor beyond the lips and the patient pushes the

tongue against the depressor. Strength is rated perceptually,

often with a 3-5 point equal-appearing interval scale or with

binary judgments of “normal” or “weak.”

Solomon & Monson (2004)




Objective measures of strength have been

recommended as more valid and reliable than subjective

measures for the assessment of tongue function, yet

subjective measures remain the more commonly used

clinical method.

Clark, Henson, Barber, Stierwalt & Sherrill (2003)




Because of this, clinicians cannot initially verify

that strength is diminished and

they cannot report increased strength following

NSOME

Only objective measures can corroborate

statements of strength needs and strength

improvement.


p

(e.g., dynamometer, force transducer, IOPI)

Without such measurements, testimonials

of strength gains are suspect.

Tongue Force Transducer

Iowa Oral Performance Instrument (IOPI)

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When tongue strength assessments were done with

a tongue depressor compared with the IOPI, it was

found that there was only a weak correlation.


Student clinicians were actually better at estimating

strength than were experienced clinicians

(but nether were very good).

Clark, Henson, Barber, Stierwalt & Sherrill (2003)

How is strength adequately

measured?


Usually with subjectivity so

statements about weakness are

questionable.


Do children with speech


Do children with speech sound disorders have

weak tongues?

Sudberry, Wilson, Broaddus, & Potter (2006)

• Used the Iowa Oral Pressure Instrument (IOPI)


• 30 typically developing preschool children and 15 with speech sound disorders.

• Children with speech sound disorders had STRONGER tongues than typically developing children!!!

Dworkin & Culatta (1980)No difference in tongue strength comparing controls with children who “lisp” and children


controls with children who “lisp” and children with a tongue thrust.

Dworkin & Culatta (1980)

“The present findings suggest that tongue


The present findings suggest that tongue strengthening exercises may be

superfluous to the correction of tongue thrusting or associate frontal lisping.”

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Tone vs. Strength• Muscle tone refers to the resilience or elasticity of

the muscle at rest.


• "Low tone" indicates less contraction of the fibers than typical.

• Observing low tone does not automatically mean that the child has weakness.

• Working on strengthening probably will not influence tone.

Clark, 2010

Summary Strength needs for speaking are very low.

We need agile movements not strong


We need agile movements, not strong movements.

NSOME probably are not adding strength.

Subjective measures of strength are not valid.

Children with speech sound disorders probably don’t have weak tongues.






Task specificity


Relevancy of NSOME to Speech

NSOME


lack

RELEVANCY

RELEVANCY is the issue

Relevancy is the way to get changes in the neural system


Context is Crucial

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Context is CrucialIn order to obtain transfer from one skill to another, the learned skill

must be relevant to the other skills.

For sensory motor stimulation to improve articulation, the stimulation must be done with relevant behaviors with a defined end goal, using

integration of skills.




Context is Crucial

“The purpose of a motor behavior has a profound influence on the manner in which the relevant neural topography is

marshaled and controlled.”

Weismer (2006)


Sh ti b k tb ll


Shooting a basketball

Why DIS-INTEGRATE?

Another non-speaking example:


Dribbling a

Basketball

Another non-speaking example:


Playing

the Piano

One final non-speaking example:

Why shoot a basketball


Why shoot a basketball

without an actual hoop?

The end goal needs to be practiced!

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One final non-speaking example:

Breaking down basketball


gshooting or the speaking

task into smaller, unrelated chunks that are irrelevant

to the actual performances is not effective.

Talk about irrelevant…

For example practicing tongue


For example, practicing tongue elevation to the alveolar ridge with the desire that this isolated task will

improve production of /s/ is dis-integrating the highly integrated

task of speaking.

Improving speaking ability must be

practiced in the context of speaking.


To improve speaking, children must

practice speaking, rather than using

tasks that only superficially appear

to be like speaking.

Isolated movements of the tongue, lips and

other articulators are not the actual

gestures used for the production of sounds


g p

in English.

Oral movements that are irrelevant to the

speech movements will not be effective

therapeutically.

No speech sound requires the tongue tip

to be elevated toward the nose no


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.


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Summary Only movements relevant to speaking are

effective.


The end goal—speaking–must be practiced.

Disintegrating highly integrated movements are not effective.

No speech sounds are produced with the tongue in strange positions, cheeks puffed out, etc.






Task specificity


Task Specificity

Do the same structures used

for other “mouth tasks”

Task Specificity

for other “mouth tasks”

function the same as for

speech?

Respondents who reported they believe speech develops from early oral motor

Do SLPs USE NSOME?

speech develops from early oral motor behaviors such as sucking and chewing:

Lof & Watson (2008)

60%

This means that clinicians believe that early experiences with sucking and chewing

lead directly to speech.

Task Specificity

lead directly to speech.

However, chewing and babbling have been shown to have no relation.

Early mouth movements are not precursors to speech.

Moore & Ruark (1996)

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T k S ifi it

Task Specificity

Task Specificity

T k S ifi it

Task Specificity

Task SpecificitySame Structures but Different Functions

The same structures used for speaking and other “mouth tasks” (e.g., feeding, sucking, swallowing, breathing, etc.) function in different ways depending on the task

Task Specificity

ways depending on the task.

Each task is mediated by different parts of the brain.

The organization of movements within the nervous system is not the same for speech and nonspeech.

Although identical mouth structures are used these

Task Specificity

structures are used, these structures function differently

for speech and for nonspeech activities.

The control of motor behavior

Task Specificity

is task specific, not effector (muscle or organ) specific.

There is strong evidence

Task Specificity

against the “shared control” for speech and nonspeech.

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Bonilha, Moser, Rorden, Baylis, & Bridriksson (2006). Speech apraxia

ith t l i C l b i

Task Specificity

without oral apraxia: Can normal brain function explain the physiopathology? Neuro Report, 17 (10), 1027-1031.

Bonilha, Moser, Rorden, Baylis, & Bridriksson (2006)

Finding:

Non-speech motor movements

Task Specificity

pelicited activation of different

parts of the brain than did speech motor movements.

Bonilha, Moser, Rorden, Baylis, & Bridriksson (2006)

Schulz, Dingwall, & Ludlow (1999).Speech and oral motor learning in

Task Specificity

Speech and oral motor learning in individuals with cerebral atrophy. Journal of Speech, Language and Hearing Research,

42, 1157-1175.

Schulz, Dingwall, & Ludlow (1999)

• Normal adults and adults with cerebral pathology

Task Specificity

• Practiced speech and nonspeech movements

• FINDINGS:


• Difference in the effect of learning between speech and nonspeech movements for both groups.

• There is a difference in the degree of change in cortical physiology in response to training for speech and

Task Specificity

physiology in response to training for speech and nonspeech tasks.

• It cannot be assumed that the type of pattern of cortical or behavior adaptations are equivalent for speech and nonspeech tasks.

• Important to consider “speech motor control” that is different from other motor control.


Task Specificity

Ludlow, C., Hoit, J., Kent, R., Ramig, L., Shrivastav, R., Strand, E., Yorkston, K., & Sapienza C (2008) Translating principles ofSapienza, C. (2008). Translating principles of neural plasticity into research on speech motor control recovery and rehabilitation. Journal of Speech, Language and Hearing Research, 51, S240-S258.

Ludlow et al. (2008)

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• Changes in neural function with practice are limited to the specific function being trained.

• For example, training on lip strength will only

Task Specificity

benefit the neural control for lip movement and force with no spontaneous transfer to speech production.

• Changes occur only in the neural substrates involved in the particular behavior being trained.

Ludlow et al. (2008)

Yee, Vick, Venkatesh, Campbell, Shriberg, Green, Rusiewicz, & Moore (Nov., 2007).

Task Specificity

Green, Rusiewicz, & Moore (Nov., 2007). Children’s mandibular movement patterns in two nonspeech tasks.

74 36-60 month olds:

42 with “speech delay”

32 typically developing

Task Specificity

32 typically developing

2 tasks:1. Silent jaw oscillations (imitation of speech

movements in response to a model) 2. Mastication (chewing a single Goldfish

cracker)Yee et al. (2007)

Analyzed the cyclic movements of the mandible across groups and tasks

FINDINGS

Task Specificity

FINDINGS

• Speech and nonspeech tasks exhibited distinct patterns

• Typically developing and children with speech disorders did not differ

Yee et al. (2007)

7 Research Examples of Task Specificity

Babbling and Early Oral Behaviors

NOT related to each other

Moore & Ruark (1996)


Speech and Swallowing• Dysphagia with speech problems• Dysphagia without speech problems• Speech problems without dysphagia

Green & Wang (2003); Martin (1991); Ziegler (2003)

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S h d S ll i


Speech and SwallowingCan strengthen the oral structures for the oral phase of swallowing but it will

have no impact on speaking

Robbins et al. (2005)


Strengthening VPCan strengthen the VP complex, but it

does not reduce nasalized speech

(many studies since the 1960s)


Breathing for SpeechDifferent than breathing at rest or

during other activities

e.g., Moore, Caulfield, & Green (2001)


Tongue Thrust Therapy

Oral myofunctional therapy improves the tongue thrust, but not speech

productions

Gommerman & Hodge (1995); Christensen & Hanson (1981)


Diadochokinetic Syllable RepetitionSyllable repetition and speech production

rate and accuracy are unrelated; training these movements will not improve speech.

McAuliffe, Ward, Murdoch, & Farrell (2005)


Silent Tongue MovementsSilent tongue movements produced

symmetric brain activation in the right and left primary motor regions; phonation with tongue movements produced activation in

the left hemisphere.Terumitsu, Fujii, Suzuki, Kwee, & Nakada (2006)

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Summary of 11 Research StudiesSummary of 11 Research StudiesSpeech and Nonspeech are different for:

Other Research Examples of Task Specificity

•facial muscles

•jaw motion

•jaw operating space

•jaw coordination

•lingual movement

•lip motions

•levator veli palatini

•mandibular control

Weismer (2006)

Summary The same oral structures function differently for

speech and for nonspeech movements.

Task Specificity

p p

Working on nonspeech activities will not develop the necessary neural pathways for speaking.

Speech is special and unlike other oral movements.






Task specificity


Warm-Up, Awareness and Metamouth

Do SLPs USE NS-OME?

Rank order of most frequently identified “benefits” of these exercises:

1. Tongue elevation


3. Tongue strength

4. Lip strength




8. Drooling control

9. VP competence

10. Sucking ability

Lof & Watson (2008)

2 points about this…1 Warm-up from a physiological


1. Warm up from a physiological point of view

2. “Meta-mouth” awareness

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Warm up from a physiological point of view

Awareness and “Warm-Up”

Purpose of warm-up muscle exercise:

To increase blood circulation so muscle viscosity drops, thus

allowing for smoother and more elastic muscle

contractions



When is muscle warm-up appropriate?

When a person is about to initiate an exercise regimen that will maximally tax the

system (e.g., distance running, weight lifting)



When is muscle warm-up NOT appropriate?

Muscle warm-up is not required for tasks that are

below the maximum

(e.g., walking, lifting a spoon-to-mouth)



When waking up in the morning it is doubtful that many peopleit is doubtful that many people

warm-up their arms before dressing, or warm-up their

mouths before uttering their first “good morning” because the

muscles are already prepared for such tasks.

Metamouth

?

Providing some form of knowledge

Metamouth

about the articulators’ movement and placement

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For articulation awareness, children age 5 and 6 years have very little

Metamouth

age 5 and 6 years have very little consciousness of how speech sounds

are made; 7 year olds are not very proficient with this either.

Klein, Lederer & Cortese (1991)

Children can make use of metamouth knowledge perhaps

Metamouth

metamouth knowledge perhaps after age 7 if they have the

“…cognitive maturity required to understand the concept of a

sound.”

Koegel, Koegel, & Ingham (1986)

It appears that young children cannot take advantage of the non

Metamouth

cannot take advantage of the non-speech mouth-cues provided during

NSOME that can be transferred to speaking tasks.

SummaryMuscles do not need to be warmed up if they

are not being taxed.


g

NSOME do not “wake up” the mouth for speaking.

Children probably cannot make use of the mouth cues provided during NSOME that will aid in articulatory movements for speech.

Disorders that SLPs Use NSOME

The L O N G

list oflist of disorders that clinicians use

NSOME in therapy…


Childhood Apraxia of Speech (CAS) Dysarthria Structural anomalies (e.g., clefts)

D d Down syndrome In early intervention Late talkers Phonologically impaired Hearing impaired Functional misarticulators

Lof & Watson (2008)

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NSOME and

Childh d A i f S h


Childhood Apraxia of Speech

(CAS)

It is puzzling why clinicians would use NSOME, especially for children with CAS.

Disorders that SLPs Use NSOME—CAS

By definition, children with CAS have adequate oral structure movements for nonspeech activities but not for volitional speech (Caruso & Strand, 1999).

There can be no muscle weakness of children with CAS, so there is no need to do strengthening exercises.


If there is weakness, then the correct diagnosis is dysarthria, not apraxia.

“The focus of intervention for the child diagnosed with CAS is on improving the

planning, sequencing, and coordination of


p g, q g,muscle movements for speech. Isolated

exercises designed to "strengthen" the oral muscles will not help. CAS is a disorder of

speech coordination, not strength.”

ASHA Position Paper and Technical Report (2007)

NSOME and


NSOME and Cleft Lip/Palate

The VP mechanism can be strengthened through exercise, but added strength will not improve speech production.

Disorders that SLPs Use NSOME—Cleft Lip/Palate

Blowing exercises are not an appropriate therapeutic technique.

Peterson-Falzone, Trost-Cardamone, Karnell, Hardin-Jones (2006)

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See these references:• Peterson-Falzone, Trost-Cardamone,

Karnell, Hardin-Jones (2006), ( )

• Goldening-Kushner, K. (2001)

• Ruscello (2008)

“Do not invest time or advise a parent to invest time and money addressing a muscle strength problem

that may not (and probably does not) exist. It is very frustrating to see clinicians working on “exercises” to


frustrating to see clinicians working on “exercises” to strengthen the lips and tongue tip when bilabial and

lingua-alveolar sounds are already evident in babble, or when bilabial and lingual/lingua-alveolar functions

are completely intact for feeding and other nonspeech motor behaviors.”


“Having a repaired cleft does not mean a child will lack the muscle strength needed to produce

consonant sounds adequately. The presence of a cleft palate (repaired or unrepaired) has no


p ( p p )bearing on tongue strength or function (why would it?). The majority of children who demonstrate VPI do so because their palate is too short to achieve VP closure. Muscle strength or lack thereof is not

a primary causal factor associated with phonological delays in this population.”


“…blowing should never be used to “strengthen” labial or soft palate musculature; it does not work.

Children who appear to improve over time in


therapy when using these tools are likely demonstrating improvement related to maturation

and to learning correct motor speech patterns. Had therapy focused only on speech sound

development, these children probably would have shown progress much sooner.”


“Blowing exercises, sucking, swallowing, gagging, and cheek puffing have been suggested as useful in

improving or strengthening velopharyngeal closure and speech. However, multiview videofluoroscopy


p pyhas shown that velopharyngeal movements of these

nonspeech functions differ from velopharyngeal movements for speech in the same speaker.

Improving velopharyngeal motion for these tasks do not result in improved resonance or speech. These

procedures simply do not work and the premises and rationales behind them are scientifically unsound.”

Goldening-Kushne, 2001

NSOME for

Non-Motor Speech Disorders


Non Motor Speech Disorders

(e.g., Late Talkers, Children in early intervention, Hearing impaired,

Phonological disorder, etc.)

—

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It makes no logical sense that motor exercises could help improve the

speech of children who have non-motor

Disorders that SLPs Use NSOME—Non-Motor Problems

speech of children who have non-motor problems, such as language-phonemic-phonological problems, like children in Early Intervention diagnosed as late

talkers.

Why would children with a language-based sound

Disorders that SLPs Use NSOME—Non-Motor Problems

g gproblem improve with a motor-

based treatment approach?

NSOME and


Children with Dysarthria

Should NSOME be used for children with the diagnosis of

Disorders that SLPs Use NSOME—Dysarthria

dysarthria?

What does the acquired dysarthria literature say?

“…strengthening exercises are probably only appropriate for a small

number of patients ”


number of patients.”

“…weakness is not directly related to intelligibility..for patients with ALS.”

Duffy (2005)

Mackenzie, C., Muir, M., & Allen, C. (2010). Non-speech oro-motor exercise use in acquired dysarthria management:


use in acquired dysarthria management: Regimes and rationales. International

Journal of Language and Communication Disorders, 1-13.

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81% of SLPs in Scotland, Wales, and Northern


Ireland, working with adult-acquired dysarthria, use

NSOME

Mackenzie, Muir, & Allen (2010)

“That NSOME are appropriate in dysarthria is part of the folklore of SLT, and folklore may be a potent influence,


and folklore may be a potent influence, even impending the adoption of

approaches which have scientific validity, in favour of what is handed down by word

of mouth or demonstration.”

Mackenzie, Muir, & Allen (2010)

Should NSOME be used for children with the diagnosis of dysarthria?


Based on the adult acquired dysarthria literature, it appears that NSOME are not recommended as a technique that can

improve speech productions.

Duffy (2005); Yorkston, Beukelman, Strand, & Hakel (2010)

Evidence Against NSOME

Evidence


Based Practice

EBP

There are a limited number of


published (peer reviewed) articles that have sufficient

scientific rigor.

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ASHA National Center for Evidence-Based Practice in Communication Disorders


Communication Disorders (NCEP)

Purpose:To conduct evidence-based systematic reviews

on NSOME

McCauley, Strand, Lof, Schooling, & Frymark, (2009)

ASHA National Center for Evidence-Based Practice in Communication Disorders (NCEP)

Findings:


Based on the 8 published peer-reviewed articles, the evidence is equivocal due to the lack of well-designed experimentally

controlled studies with adequate statistical power and adequate description of

subjects.

McCauley, Strand, Lof, Schooling, & Frymark, (2009)

CONVINCING evidence that they do not work


do not work

NO real data that supports their use

There is some research evidence, most of which has been presented at


most of which has been presented at various

ASHA Conventions…

RESEARCH: Non Speech Oral Motor Exercises

Do Not Work

1. Christensen & Hanson (1981)

2. Gommerman & Hodge (1995)

3. Colone & Forrest (2000)

4 Occhino & McCane (2001) 12345

64. Occhino & McCane (2001)

5. Abrahamsen & Flack (2002)

6. Bush, Steger, Mann-Kahris, & Insalaco (2004)

7. Roehrig, Suiter, & Pierce (2004)

8. Guisti & Cascella (2005)

9. Hayes (2006)

10. Forrest & Iuzzini (2008)

78

9 10

1. Fields & Polmanteer (2002)

RESEARCH: Non Speech Oral Motor Exercises

Do Work

11

But this study has MANY methodological fatal flaws (more on this later)

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There are 11 studies il bl 10 th t h h


available, 10 that have shown that NSOME were not

effective as a treatment approach.



LEVEL Ib: STRONG Well designed randomized controlled study

LEVEL Ia: STRONGEST Well-designed meta-analysis of >1 RCT

LEVEL Ib: STRONG Well-designed randomized controlled study

LEVEL IIa: MODERATE Well-designed controlled study without randomization

LEVEL IIb: MODERATE Well-designed quasi-experimental study

LEVEL IV: WEAK Opinion of authorities, based on clinical experience

LEVEL III: LIMITED Nonexperimental studies (i.e., correlational and case studies)

RESEARCH:Non Speech Oral Motor Exercises Do Not Work

Christensen and Hanson (1981)

• 10 children • Aged 5;8 to 6;9 years• 14 weeks• 14 weeks• Half of the children received only articulation therapy; the other

half received articulation and “neuromuscular facilitation techniques”

• Both groups made equal speech improvements• The exercises did not help for better speech sound production

BUT were effective in remediating tongue-thrusting (probably due to task specificity)

Gommerman & Hodge (1995)

• 16 year-old girl with tongue thrust and sibilant distortions


• A Phase, no treatment; B Phase, myofunctional treatment; C Phase articulation therapy.

• Tongue thrust was eliminated with myofunctional therapy but speech was unchanged.

• With articulation therapy, sibilant productions improved.

Colone & Forrest (2000)

• Monozygotic twin boys age 8;11 year old• Motor treatment for Twin 1, phonological


treatment for Twin 2• NO improvements with motor training (Twin 1);

good results using a phonological approach (Twin 2)

• When Twin 1 received phonological treatment, there were the same improvements as Twin 2

Occhino & McCane (2001)• Single Subject Design (A-B-C-B-C)• 5 year old child• Results were that oral motor exercises alone


Results were that oral motor exercises alone produced no improvement in the articulation of one of two phonemes

• Also no improvements in oral motor skills• Oral motor exercises prior to or along with articulation

therapy did not have an additive or facilitative effect• Articulation improved with articulation therapy

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Abrahamsen & Flack (2002)

• Single Subject Design

4 year old child


• 4 year old child

• 10 hours of individual treatment

• Used blowing, licking, and oral stimulation

• No evidence of effectiveness in changing speech-sound productions

Bush, Steger, Mann-Kahris, & Insalaco (2004)

• ABAB Withdrawal Single Subject Design• 9 year old boy


• 9 year old boy• OME added to articulation treatment, then

removed, then re-added• /r/ /s/ /z/ /l/• “Oral motor treatment did not improve or reduce

treatment's success.”

Roehrig, Suiter, & Pierce (2004)

• AB or BA Single Subject Design• Six 3;6 - 6;0 boys and girls


• 15 weeks total Tx: (A) Tradition, production-based Tx twice a week for ½ hour; (B) Passive OME and traditional Txtwice a week for ½ hour

• “The addition of OME to the traditional articulation therapy approach did not add to participants overall progress; improvement following therapy with OME was not different from improvements following articulation therapy alone.”

Guisti & Cascella (2005)

• Single Subject Design using 2 boys and 2 girls

• All in first grade


• Followed Easy Does it for Articulation: An Oral Motor Approach (1997)

• 15 ½ hour individual treatment sessions

• No evidence of effectiveness in changing speech-sound productions

Hayes (2006)

• Six 4 year olds, 5 boys and 1 girl

• All had “functional misarticulations”

C b l d i i d i bj


• Counterbalanced intervention design so subjects were randomly assigned to a specific order; Oral motor approach and traditional articulation approach.

• The traditional treatment resulted in significant change; no support for using oral motor for change.

• Some support that NSOME actually hindered learning.

Forrest & Iuzzini (2008)

• 9 children, 3;3 to 6;3 years

• Alternating treatment design: 1 sound treated with NSOME 1 sound with production treatment (PT) 1 not


NSOME, 1 sound with production treatment (PT), 1 not treated

• At least 20 treatments sessions lasting 60 minutes

• RESULTS: – 30% increase in sound accuracy with PT; 3% with NSOME

– NSOME did not even improve movement control when assessed using a Volitional Oral Motor test

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Fields & Polmanteer (2002)• Eight 3- to 6-year-old children • Randomly assigned to one of two groups • Four children received 10 minutes of oral motor


Four children received 10 minutes of oral motor treatment and10 minutes of speech therapy; four children received 20 minutes of only speech therapy

• Fewer errors at the end of 6 weeks of treatment for the children who received the combination of treatments

BUT….

Fields & Polmanteer (2002)

Many methodological and statistical issues• Severity distribution not equal (speech-only group


Severity distribution not equal (speech only group more severe)

• Gender distribution not equal• The treated sounds and the equivalency of the

sounds between groups were not reported.

VERY Questionable Results

The evidence that is available…OVERWHELMINGLY


demonstrates that NSOME are not

effective in bringing about

speech-sound changes.

Based on the findings as of now, th f NSOME t b


the use of NSOME must be considered exploratory and the clients should be informed of this

prior to initiating their use in therapy

Recent Reviews of the Literature


CLINICAL FORUM: The Use of Nonspeech Oral Motor Treatments forNonspeech Oral Motor Treatments for

Developmental Speech Sound Production Disorders: Interventions

and Interactions

Language, Speech and Hearing Services in the SchoolsJuly, 2008

Many SLPs use a combination of treatment approaches, so it is difficult to “tease apart”

which approach is providing therapeutic

What about Combining Treatment Approaches?

benefit.Whenever intervention approaches are

combined, it is unknown if and how they actually work in conjunction with each

other to enhance performance.

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There is much evidence that the NSOME portion of combined treatments is irrelevant to speech

improvements.

NSOME b bl d t h th hild h

What about Combining Treatment Approaches?

NSOME probably do not harm the child when used in combination with other approaches.

SLPs should eliminate the approach that is not effective (i.e., NSOME) so as to not waste valuable therapy time with an ineffectual

technique.

that are used in articulation therapy are

Phonetic Placement CuesPhonetic Placement Cues

articulation therapy areNOT the same as

NSOME

NSOME are a

NSOME are NOT Goals

procedure, NOT a goal!!!

Oral motor exercises are a procedure, NOT a goal!!!

The goal of therapy is NOTto produce a tongue wag to

NSOME are NOT Goals

to produce a tongue wag, to have strong articulators, to

puff out cheeks, to blow “harder” horns, etc.

Oral motor exercises are a procedure, NOT a goal!!!

R th th l i t

NSOME are NOT Goals

Rather, the goal is to produce intelligible speech

Why Do SLPs Use NSOME?

Some potential reasons why NSOME is used so frequentlyNSOME is used so frequently in the remediaton of speech

sound disorders:

Lof (2008)

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The procedures can be followed in a step-by-step “cookbook” fashionThe exercises are tangible with the


appearance that something therapeutic is being done at a physical level (even if the disorder is not motor in nature as would be the case for hearing impairment or phonological impairment)

There is a lack of understanding the theoretical literature addressing the dissimilarities of speech-nonspeech


p pmovements

The techniques can be written out to produce handouts to give to caregivers for use outside of the therapy setting

There are a wide variety of techniques and tools available that are attractively presented for purchase


Many practicing clinicians do not read peer-reviewed articles but instead rely on unscientific writings (e.g., web sites, the popular press, marketed therapy tools, etc.)

They attend non-peer reviewed activities(e.g., continuing education events) that encourage the use of these activities


encourage the use of these activities

Parents and occupational/physical therapists on multidisciplinary teamsencourage using NSOME

Frequently, other clinicians persuade their colleagues to use these techniques, which is reminiscent of a statement by


which is reminiscent of a statement by Kamhi (2004) who stated, “…no human being is immune to hearing a not-so-good idea and passing it on to someone else.”

Been burned before….

Clinicians often resort to “because it works”

observations

Remember, we wrongfully embraced

facilitated communication!!

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A Helpful

Reference

Nov., 2008

CLINICAL FORUM:The Use of Nonspeech Oral

Motor Treatments for

Another Helpful Reference…

Motor Treatments for Developmental Speech Sound

Production Disorders: Interventions and Interactions

Language, Speech and Hearing Services in the SchoolsJuly, 2008

What questions/commentsdo you have?

1

Updating Evidence Against Updating Evidence Against Nonspeech Oral Motor Exercises Nonspeech Oral Motor Exercises

(NSOME) for Speech Sound (NSOME) for Speech Sound ProductionsProductions

Gregory L. Lof, PhD, CCC-SLPDepartment Chair/Professor

July, 2011

Boston, MA

moderated by: amy hansen, m.a., ccc-slp, managing...

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