SEASON 11, EPISODE 5

[INTRODUCTION]

[0:00:13] ANNOUNCER: Welcome to SLP Learning Series, a podcast series presented by speechtherapypd.com. The SLP Learning Series explores various topics of speech-language pathology. Each season dives deeper into a topic with a different host and guests who are leaders in the field. Some topics include stuttering, AAC, sports concussion, teletherapy, ethics, and more. Each episode has an accompanying audio course on speechtherapypd.com and is available for 0.1 ASHA CEUs. Now, come along with us as we look closer into the many topics of speech-language pathology. 

[INTERVIEW]

[0:01:03] MM: Hi. Welcome to Making Sense of Myo. My name is Madi Metcalf and I'll be your speechtherapypd.com host for this podcast, Making Sense of Myo. This episode is 60 minutes and will be offered for 0.1 ASHA CEUs. 

Our guest today will be Hallie Bulkin. Hallie's financial disclosures include Ð she receives an honorarium from speechtherapypd.com for her guest appearance on this podcast. She's the owner of Hallie Bulkin LLC where she mentors other business owners in the online space. Hallie is also the owner and creator of an online continuing education platform, Elevation Movement LLC, which includes Feed The Peds: Foundations of Pediatric Feeding and Swallowing. The Myo Method Course, the CMT, Certified Myo Functional Therapist, the Myo Membership, The Untether Podcast and the Real Biz Mastermind for Private Practice Mentorship. Hallie is the owner of a private practice, Little Sprout Therapy in Metro Myo, which operates in various states. Hallie does not have any relevant non-financial disclosures. For myself, I am getting an honorarium for hosting this podcast and have no relevant non-financial disclosures. 

Now, without further ado, we welcome our presenter, Hallie Bulkin. Hallie Bulkin, MA, CCC-SLP, CMT, COM is a feeding specialist, certified myofunctional therapist and speech-language pathologist. Hallie is the founder of Feed The Peds, a comprehensive 12-week course on the foundations of pediatric feeding and swallowing, the Myo Method, intro to the Myo course, The Myo Membership and the Untethered Podcast. 

Allie also is a founder and director of Little Sprout Therapy in Metro Myo, a pediatric clinic providing feeding therapy, orofacial myofunctional therapy, speech-language therapy and occupational therapy in Washington, D.C., Maryland, Virginia, New York, New Jersey and Florida. Her team provides myofunctional therapy to adults too. 

Hallie specializes in treating infants, toddlers, children with tethered oral tissues, feeding delays and disorders, and orofacial myofunctional disorders. When Hallie is not running her private practice or teaching and mentoring colleagues in the feeding, myo private practice and online business world, you'll find Hallie hanging with her family and fur baby. 

Fun fact, Hallie and both her daughters were tongue and lip-tied. Received myofunctional therapy, frenectomies, and underwinding with growth appliances. 

Hi, Hallie. Welcome to the Making Sense of Myo podcast. 

[0:03:17] HB: Hello, Maddie. Thank you so much for having me.

[0:03:20] MM: Yeah. Absolutely. I'm thrilled to have you on. You are the person that kind of got me interested in the myofunctional world. I'm so happy to have you on today.

[0:03:29] HB: I love hearing that. I know you were in the membership at one point. And so, when I Ð 

[0:03:33] MM: I was.

[0:03:34] HB: Ð I saw your name come through, I was like, "Oh, we got to do this." 

[0:03:36] MM: Oh, that's awesome. Whenever I first got in, I messaged you and was like, "Is this something that I should do?" And I think you are the one that kind of directed me into taking Sandra's course. And then I was in the Myo Membership for a little bit to make sense of it. It was all super helpful when I was first getting in. 

Today we're going to really dive into what is a myofunctional evaluation. How do we do it? What does it include? Do we do feeding and articulation in myofunctional evaluation? Yeah, let's get into it.

[0:04:03] HB: Absolutely. Just answering the question, what does a myo eval even consist of? In my course that you mentioned, we do have a form that we provide. An actual myo evaluation form. And it walks you through everything that you're going to assess for. I'm going to tap into that in a moment. But before we know what to assess, I think it's also really important that we know what typical looks like. And I think that's true for any area that we assess Ð 

[0:04:28] MM: Absolutely. 

[0:04:29] HB: In myo, just very simply put, we do teach tongue up, lips closed, teeth apart, breathe through your nose. And that refers to correct oral rest posture. And I know we'll talk more about the goals of myo later. But we want optimal function of our oral and our orofacial musculature for bolus prep also, and for speech production and initiating that swallow, which kind of goes more with bolus prep than speech. But anyways. 

When there are signs or symptoms that are impacting these areas, that's when we go, "Okay, let's do an assessment to see if there's an orofacial myofunctional disorder or an OMD present." And so, before I jump further into that, I want to just define what an OMD is real quick. 

And so, that involving the oral and orofacial musculature that interfere with normal growth, development, function of our orofacial structures. And we see OMDs in children, adolescents, adults, right? It's across the lifespan. But it can co-occur then with a variety of speech and swallowing disorders. And it may also reflect the Ð there could be interplay between learn behaviors, physical and structural variables, genetic, environmental factors. And there is some research behind this that has been done that speaks to all of this.

And so, to understand like what we assess for in a myo eval, we also do need to know the signs and symptoms. But we'll talk about that a little bit later. When assessing, just like any other assessment, we're going to start with if you've given the patient an intake, they've completed the intake. It's interesting. Sometimes I like to review the intake first. And other times I actually will just kind of glance over it just to see what symptoms they filled in. And I think it leads to a much more natural conversation with the patient. 

But when I was getting started, I would sit there with that intake and I would literally copy and paste over everything they filled out onto my notes. Because I was like, "I want to see everything they filled out so I can dive deeper." And I think that's still a great strategy. 

What I learned though was when I had like these preconceived notions of like what I wanted to ask and where things were going to go without Ð I glance over it briefly. It kind of directed the conversation. And so, I really like to review that after the eval and after I've met the person at least with myo disorders. And especially when it's more of an adult or an older child versus like a younger child where the parents are reporting, then I'll dive in a bit more. 

But that main complaint or that chief complaint, the main concern. Why are they here? Why are they coming to us for the evaluation? That's what I'm most interested in and that is where I will have conversation with either the parent or the patient around, "Hey, well, what brings you here today? What's going on?" 

And so, I think that can give us so much valuable information and have really help direct the evaluation further. Obviously, we're going to gather information on medical history, developmental history, and other relevant background information like we always do when we do any kind of an eval. And like I said, much of this can also be gathered from a comprehensive intake form. But I don't think there's a right way or wrong way per se as to how you go about getting the info.

[0:07:30] MM: I love that idea of Ð I'm definitely still in the Ð I copy and paste everything over and then I make my highlights of what I think is the most relevant thing to kind of discuss. But I love that idea of kind of going with a little bit more of an open mind. Because then you really do. If you listen to your patient long enough, they'll tell you exactly what their problem is. I think that's a really interesting way to go about getting a case history.

[0:07:48] HB: Yeah. 

[0:07:49] MM: Do you do a myofunctional evaluation on every patient you see? Or do you save your myofunctional evaluations for only some patients? 

[0:07:59] HB: I mean, in my private practice, we actually get phone calls specifically for myo evals. But we'll listen to what the chief complaint is. Like, why are they calling? Is it a kiddo? If they are calling for a speech sound disorder and whether they're new to this issue or they've been in speech before, typically we're going, "Do we think we want to do a myo eval? Maybe?" 

We also kind of draw the line based on the age that myo is appropriate for. Myofunctional therapy is really designed for a child who is at least at the level of a four-year-old cognitively. Cognitive age. Not chronological age. Up through adulthood, right? You could go up until literally death, like 99, 100, 101-years-old. I mean, however far you want to go. 

But under that age, it really falls under the scope of a pediatric feeding therapist. And that's something else that we teach too. Because a lot of what we're doing as pediatric feeding therapists, especially if you're trained in myofunctional OMDs, and myo and then tethered oral tissues, that falls under what we do in a pediatric feeding eval. A sensory oral motor pediatric feeding eval and therapy. And so, that really requires like a licensed feeding therapist in SLP or an OT for example to dive into it with that age group. 

What I'm talking about right now and what we'll talk about today really applies more to the four-plus crowd. And so, we are more inclined in that age group to do a myo eval when they come to us with certain signs and symptoms or alongside the other speech or language eval that we may be doing. I know we'll talk about that a bit too.

[0:09:25] MM: Yeah. I know in my clinic we're trying really hard to kind of stay in that specialty of myofunction and feeding disorders. And so, for that four and up, we kind of do a myofunctional evaluation on all of our kids. And that takes the place of our in-depth oral mech exam. And it's really interesting. Because most of these kids that were coming in for speech sound disorders, they have that underlying myofunctional disorder. Yeah.

[0:09:46] HB: Yeah. Well, in the oral mech exam that I learned at least when I was in grad school is like it was sort of like a good jumping-off point for what we do in a myo eval. Because we're looking at airway. Head, neck, face. We're looking at the jaws, the lips. Inter-oral assessment. That oral phase swallow between everywhere from the bolus prep to the actual swallow, oral phase part of the swallow. 

And then we may even Ð if we're doing a screening or a myo eval, we may also be screening or assessing for voice fluency or articulation too if an SLP obviously is the one who's doing that evaluation. 

[0:10:19] MM: I would love if you kind of walk us through what that process looks like.

[0:10:23] HB: As far as airway goes, one of the big things we look at is oral habits. And we call them noxious oral habits. Things that we shouldn't be doing like sucking our thumb, biting our fingernails. And these are things that Ð it's like I always say, it's putting something that's not food in your mouth and it's become habitual and it's interfering with nasal breathing and correct oral rest posture. And so, we can dive more into that later. 

But if there's any snoring or audible breathing, if we can hear breathing, we shouldn't hear someone breathe. When people are waking frequently, we ask about that. Or if they wake rested. We ask about like allergies and food sensitivities and if there Ð we do like a little assessment for the narrow to see if it's patent or if there's any blockage appearing. If do we need to refer onward? Are there any obvious breathing patterns that we see? Do they seem to be like breathing really shallowly through their clavicle or their neck and shoulders versus they're belly breathing or their diaphragm? Is there any history of asthma? Or like in older teens up or through adults, any history of smoking or even vaping? All of these things, people don't realize it, these all contribute to airway issues or it gives us insight into airway issues. And so, that's super foundational.

And then moving like into kind of like the head, neck, face. Just from a posture standpoint, we look at the whole body posturally. We look at the shoulders when they're seated or versus standing. We look at their pelvis position. We look at the position of the neck. And then we'll also look at the facial profile. The shape and the symmetry. Yeah.

[0:11:53] MM: Do you make comments on body posturing, pelvic tilt, and head posturing in your evaluation even though you're not a PT?

[0:11:59] HB: Yeah. What we'll do Ð because we're not diagnosing. And I'll talk about this also once we get more to like talking about the teeth and malocclusion. A lot of times, we are checking things off for our own information. And that gives us good information as to whether or not we want to refer, right? 

If I'm referring, I want to basically be able to refer and say, "Oh, I noticed that this patient tends to tilt their pelvis anteriorly or tilt their pelvis posteriorly when seated, when standing, when drinking, when eating, when speaking." Whatever. Right? Their one shoulder appears to sit lower than the other.

I'm describing more the signs and symptoms I'm seeing. I'm not diagnosing. And I think this is important because it's all so interconnected and we see a lot of patterns when working with this population. And so, if we can kind of pull this whole big picture together for the patient sitting in front of us and go, "Okay, we are now like the sounding board." Right? "We see these various signs and symptoms. These things are going on. I want you to go see this person." And when they say, "Well, like why do I need to go see that person? Can't you help me with that?" Well, no. This is what's in my scope. This is what's in their scope. This is what's my expertise or this is theirs. And I think it just helps to describe to a patient, especially when you take photos and you can show them. It really helps to make sense of it for them. 

And I also think, especially in your adult patients, they gain a sense of hope. And they're like, "Oh, wow. Somebody can help me." Because a lot of them have been runaround for a very long time amongst people, which is a whole another conversation for another day. But, yeah. Yeah. It really goes to like not all these things are things that we are diagnosing, but we are identifying signs and symptoms that we see.

[0:13:34] MM: I love that. Because we might not be able to diagnose, but we can make observations and we can record those observations. And then that gives us the ability to make the correct referrals that we need to make sure that we get that holistic approach. And I feel like that holistic approach really is what myofunctional therapy is after. 

[0:13:48] HB: Yes. 

[0:13:48] MM: We want to treat the person as they are and help improve their overall quality of life starting with their respiration. Yeah, I love that. Thanks for explaining that.

[0:13:57] HB: Yeah. Well, and then we kind of go into the stuff that's more in our scope to diagnose or Ð and we say, we're not in the business of moving bone or teeth, right? As myo therapists, we are in the business of dealing with the soft tissue and informing the soft tissue. Can that have an impact or can it influence hard tissue and bone? Yeah. I mean, it can. But we can't make those promises. We can't say this X, Y, and Z is going to happen. But we still then have to look at the jaw. 

And so, that's one of our big sections on our eval form too, is the jaw, both our mandible and our maxilla. What is the position? Between the two of them, where are they at rest? Then you're not eating, you're not speaking, what is the relationship between the tongue and the mandible? What is that lingual mandibular dissociation? Can we dissociate the tongue from the jaw? Or do they move together as one unit? Right? 

And later on in our form, when we get into like the lips, we look at that with the lips and the jaw as well. And with jaws, we're also looking at how does the mandible move when they're opening and closing? And is the mentalis muscle and the masseter Ð or those masseter muscles, are they tight? Are they even? Uneven? Does it appear that like we're compensating a bit? 

And then the temporomandibular joint. A lot of signs and symptoms around that TMJ, that TM joint. And so, we do ask about things like clicking or popping, bruxing or clenching. Is there discomfort? Are you someone who gets headaches? Do you get migraines? Has this been something? Do you chew through night guards? We want to know this information because it's so very telling. 

And then beyond the jaw, going into the lips specifically, are those lips open and closed? Or closed at rest? And is it a little bit or a lot? We can measure that too. We can get that interlabial gap measurement to see like, "Okay, you know what? Right now, the lips are sitting apart just like a couple millimeters. Are they congested? Do they not normally have their lips parted? Or are they like Ð is the mouth like hinged open and there's like 10 millimeters between the upper and lower lip?" And we're like, "Okay, this is probably not just like a cold. This is probably more an insight into what their oral rest posture actually looks like." 

And then can they close the lips easily or not? Is there tension on the face? Is there bunching in the mentalis? Is it hard to do because they can't breathe through their nose? Which kind of goes back to like our earlier airway section. And I mentioned before, the mandibular labial dissociation. Can we spread and round our lips? Can we move our lips without our jaw like shifting with it as one unit? And can we round the lips to then like suction? Kind of do that like kissing suction to pull air in? We should be able to do that because that's what's required to drink properly from a straw. 

A lot of these things that I'm saying for some people are kind of like, "Huh? Why? Why would we need to do that?" Well, these are all functional movements that we do whether you realize it or not. When we're eating, and when we're speaking, and when we're just resting and breathing.

[0:16:45] MM: Yeah. Let's go ahead and jump into the intraoral piece. 

[0:16:49] HB: In the intraoral assessment, basically we're looking at dentition. And I'm not going to go like too deep into this, right? But we want to know if they've had any past or current ortho. And the appear of Ð we look at the appearance of the hard pallet. What does the tongue look like? The uvula, the tonsils. What is that tongue resting position? This is a huge area. And I think this is also going to speak directly to that next question on the interaction between myo, and speech and feeding. 

Can we elevate? Can we depress our tongue? Can we lateralize side to side? Can we retract it backwards? Can we make a bowl? Can we narrow our tongue? Can we widen our tongue? Can we click our tongue? Can we suction it to our palette? All these big things that people I don't think realize are such a huge component of what we do on a day-to-day basis. 

Yeah. And then are there tethered oral tissues at play that are impacting the lips, the tongue or the cheeks? And is there not enough space in the palette? Does the tongue not fit up in the top of the mouth? Because that's a big one that impacts speech and feeding too. 

[0:17:43] MM: I also just want to like talk about the intraoral section. Can the tongue lateralize? Protrude? Elevate? That goes right back to that jaw-tongue dissociation. And so, when I have graduate clinicians now, I always tell them, "We don't just want to see can they do it? We want to look at the quality of how they're doing it." Because I know, whenever I started doing like oral mech, it was like, "Okay, can you stick your tongue out?" Whenever I'm doing that, my jaw is like moving up and down. My tongue is touching my chin. It's not like a nice floating tongue. I don't have a whole lot of control. Lateralization would be like Ð and my jaw is sliding and following my tongue. Elevation. I can elevate to the inside of a pillow. But my jaws closing. That's hard to coordinate. 

And so, we don't just want to see like check the box, "Oh, I saw them their tongue out." "Oh, I saw them move it side to side." What's the quality of that movement? What's the control and the coordination like? What's the stability like? 

[0:18:36] HB: Yeah. Right. Right. Exactly.

[0:18:37] MM: Take me to that next step.

[0:18:39] HB: Yeah. And when we look at like the oral prep phase for the prep and swallow, the oral phase of the swallow, we are looking at bolus collection. We're observing them eat food in different consistencies. Crunchy, soft, solids. Puree off a spoon. We'll watch them drink a thin liquid. And we look at like how do they clear the spoon and how are they chewing. And what is their tongue position during their swallow for both solids and liquids? Can they swallow pills? Do they need clean up swallows afterwards? Is there any facial tension or compensation present? As you were talking about, are there compensations that they've been carrying for a while? Probably, if there's an OMD at play, right? Do they [inaudible 0:19:13]? 

And so, I think that when we talk about like assessing for speech and feeding during a myo eval and kind of like this overlap in signs and symptoms absolutely is a part. And in my practice, we Ð if we're doing a screening, we always screen for myo and/or feeding at the end of the speech-language screening. It can take literally two to three minutes. We watch them eat a snack. And that gives us so much information. That tells us whether or not a full eval is warranted. 

And that can be done during eval too, right? And we assess the oral prep and oral phase of the swallow very quickly. Or I should say we screen it very quickly. And that just tells us if further assessment is needed. 

I think in talking about the overlap in the signs and symptoms and kind of diving into speech, and feeding, and myo and all that fun stuff, a tongue that rests low and forward, whether the jaw is open or closed Ð because I think a lot of people miss this. A lot of people don't realize. The tongue can still be laying low in the mouth even if your jaw is closed and your nasal breathing. It doesn't mean you have oral rest posture just because your lips are closed, right? 

That's the tongue that's often compensating to produce speech sounds, and bolus prep and swallow. And it can happen due to like things we talked about already like lack of tongue space. If the palette is high or narrow. Or it could be due to tethered oral tissues. If the tongue or the lips in particular are restricted or just don't have full range of motion like you were talking about too. 

And you kind of gave an example like elevating your tongue. You're like, "Look, my tongue doesn't go up without my jaw moving with it." Because there's maybe a restriction at play. And so, if there's an impact on function, that's really what we kind of have to look at. 

And so, yes, we do see this. And we often see it present in the speech side of things as a tongue thrust. And also, in feeding. We can have tongue thrusts in feeding too. And I don't think that gets talked about as much as it does in the speech side of this conversation. But that's simply an atypical tongue-forward swallow or positioning posture whether it's at rest or during speech or swallowing. And, no. Tongue thrusting is never normal. Not even in infancy, right? 

There's a difference between an infant who brings her tongue to the lower lip to breast or bottle feed. That's part of a typical presentation for feeding. But once they no longer breast or bottle feeding, that shouldn't be happening anymore. And the tongue should definitely not be going like beyond the lower lip. 

And so, a tongue thrust is an OMD by definition. And if there's airway issues on top of that and we're mouth breathing, right? Let's say maybe there's some congestion present maybe. There's enlarged tonsils, or adenoids or other inflammation, upper respiratory issues, it can make it really challenging to nasal breathe. And then that can force us to mouth breath too, right? 

And so, if you have to stop breathing or close your mouth to properly bolus prep to the food, prep that bolus and swallow, we're going have a problem if we can't breathe through our nose. And so, we do see this impact speech production too at times because enlarged tonsils can actually fill that oropharyngeal space differently than if they're a normal size. And it can make it challenging to actually pull that tongue back, to retract the tongue to produce back sounds if there is inflammation back there. Whether the tongue's restricted or not. Restriction will make it challenging too, right? 

And so, then that goes into tethered oral tissues. Like I said before, they can play a role in what tongue, the lips or the cheeks are physically able to do in terms of functioning optimally. And this may not always be so obvious. We see there's an impairment in the ability to control food. Whether it's Ð once the food goes in, lateralizing it from one set of molars to the other. Food will often stay on one side. The masseter is may be overdeveloped on that primary chewing side. 

We also see like tongue dumping where the tongue just like flips sideways dumping the food on the other side of the molars instead of maintaining that horizontal and lateral position that we should have when we're engaged in more of an adult-like rotary too. 

Mentalis may become more tense and overdeveloped when trying to keep the lips closed for chewing and swallowing. The jaw may be sliding or maybe moving in an immature chew pattern, like that munch Ð that up-down munch pattern. It has not evolved yet into a rotary chew that we should have by 36 months of age. 

And so, if the tongue also can't form a bowl shape or elevate to suction to the roof of the mouth, it's going to struggle, one, form the bolus, maintain the bolus and then engage in that peristaltic motion that's needed to initiate and complete our swallow process in that oral phase. 

And so, we tend to see more symptoms surrounding feeding and digestion. Like, picky eating, limiting foods, digestive upset, constipation with a lot of children and adults who struggle to break their food down properly and Bolus Ð form that bolus and swallow the bolus back. And there's other issues as well. But like this should just help to kind of start to paint the picture. 

And one thing I mentioned too was like picky eating. Limited foods accepted. Nutritional issues. A lot of that can follow these challenges with chewing and prepping the bolus as I mentioned. Because if you think about it, if you try to swallow foods that are not properly prepped, it may not feel good. It may hurt or it may just not feel good. 

And so, we see children who kind of go, "Yeah, that doesn't feel right." Or maybe it's falling in the wrong place in the mouth, it doesn't taste good. Or maybe they can't manage it so they're over stuffing their mouth because they can actually feel like they can manage that better and that feels safer even though it seems counterintuitive. These are just things that impact digestion. It impacts what you eat. And if you don't feel good, you don't want to eat. And if there are certain foods that you eat that you can't break down so then you don't feel good after you eat them, a child or an adult may make an association and go, "Yeah, I don't feel good after I eat that food." And so, they cut it out. Those are telltale signs. And if we have a few minutes, I'd love to just kind of go into specific articulation issues. Like the actual speech sounds that we see impacted. Is that okay? 

[0:24:49] MM: Oh, yeah. I would love if we did that. Because I think that's a huge piece of it too. Because I know that when I first started out, I had so many kids that were working on these OMD-related speech sounds and I made no progress. I made none. None. And then I learned about myo and I started implementing myofunctional techniques and I made progress. I think that's Ð 

[0:25:09] HB: That's how I found myo too. I was like meeting with a colleague and we were having Ð we were both private practice owners. She saw mostly adults. I saw mostly peds. We would like get together once a month. We referred to each other. We would just have a coffee chat, a coffee date. 

And she mentioned, she was like, "Yeah, I took this course, this myo course. And I'm not really doing myo in full and the way it's intended to be done. But I am telling you that my speech sound disorder cases are moving a heck of a lot faster." And I was like, "Wait. What?" I was like, "Hold on. You got my attention. Tell me more." 

[0:25:37] MM: Complete 180 in my practice. Yeah, let's dive into those.

[0:25:40] HB: Yeah. This is what we commonly see a struggle with, right? Alveolar sounds, back sounds. And then we see like lateral lisps, frontal lisps, right? That's kind of the overview. When it comes to the alveolar sounds, that 't', 'd', 'm', 'o', right? That requires the tip of our tongue to move independently of our mandible to allow the tip to then make contact with the alveolar ridge like we kind of talked about like a little bit earlier. And touch this spot as we call it, right? Two to three millimeters behind our upper essential incisors. A little bumpy ridge in our hard palette. 

And so, these sounds are impacted when the tip of our tongue is restricted. And the tongue often will then move, like we've kind of talked about already, as one unit with the lower jaw, which then impacts speech clarity or intelligibility. And it leads to a lot of compensations. 

And you see the same thing with back sounds. How many kids do you know who struggled to make that 'ka', 'ga', 'ung', and 'r', which is its own library of sounds. Those are sounds like Ð if anybody is stuck in therapy for a long time, often, 'r' is usually an issue, right? And so Ð not always. It doesn't always hold true. But sometimes those are the most frustrating cases because you're like, "Why can we not?" 

[0:26:46] MM: I've got the number of 'r' kids that we've had come to our clinic that have been in therapy for years. And now they're like 12, 13, 14 and they're still struggling with ÔrÕ. And then they come in, we're like, "Wow. You have a tongue-tie." "Wow. You don't have jaw-tongue dissociation. You have really poor tongue coordination." And then we focus on those things. We explicitly teach placement. We resolve the tongue-tie if that needs to happen. And then there's their 'r'. 

[0:27:09] HB: Yeah. It's magic. Right? 

[0:27:12] MM: Complete magic. 

[0:27:13] HB: Those are my most favorite cases. I mean, I feel sad because I'm like you should not have been in 12 years of therapy. Or I should not be your seventh speech therapist. However, the fact that we have a solution and that we can move to graduate from therapy and maintain your 'r' and have correct oral rest posture and all the above, it's exciting. 

[0:27:32] MM: And the hope. Going back to your Ð talking about hope with those adults earlier. The hope that we give those parents when we sit down, we're like, "This is what I'm seeing. This is the reason that I'm thinking that we're not making that 'r' sound. And I want to let you know this is overcomable." We can get them there. It's always really awesome. Because the kid gets excited. The parent gets excited. And then we get to see progress.

[0:27:52] HB: Yeah. And then you get the questions, like, "Well, why didn't anybody else look under the tongue? Or why didn't anybody else tell us this?" And we're like, "Let's not go there. Let's just focus. Let's just move forward." 

[0:28:01] MM: Hopefully, with like this podcast, and your podcast and all the other people being loud about myofunctional disorders, we will bring a little bit more anatomy and physiology back to speech pathology.

[0:28:11] HB: Yes. Please. Please. Yeah. Those back sounds, right? If the tongue can't retract properly because either it's tied. And that could be anteriorly or posteriorly. We'll see bunching or just an inability to retract at times. We talked before about like if there's inflammation in the back of the throat and the airways already restricted, the chance of a child pulling their tongue back to close off the airway even more is also Ð like we've seen issues where the child didn't really appear tied, but they had a history of upper respiratory issues and massively enlarged tonsils. Their throat was completely closed off. And once that was addressed, all of a sudden, the tongue was like, "Oh, hey I can go back here." We're like, "What? That's crazy." 

[BREAK]

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[INTERVIEW CONTINUED]

[0:29:16] HB: But, yeah. The inability to retract the tongue enough to make contact, right? The back of the tongue and the velum. They need to make contact for that 'ka', 'ga', 'ung'. And when you pull back for 'er' sounds too, we need to make contact back there. And then you've got the lisps, right? You got the lateral lisps. On that 's', 'z', 'sh-sh-sh' or 'j', right? To produce those sounds properly, the lateral borders of our tongue need to make contact with our hard pallet. It's like the sides of the tongue have to connect with the dental arch right inside of our teeth. Not on the dental arch. But it should be on the hard pallet before the teeth. We don't want it flowing over. We don't want it pushing against you're sitting between the teeth.

And so, if the palette is too narrow like it's high and narrow or it's just narrow, the lower jaw Ð or maybe sometimes the lower jaw might be unstable too. But oral tongue-tie may be a play, right? There could be other things going on. But with the lateral lisp, we see that the air is escaping sideways over the side of the tongue instead of that area being sealed off and directing the air forward. And that's where we get that slushy or wet speech quality. 

And, no. Lateral lisps and frontal lisps are never developmentally appropriate. Just to put that out there. And then the frontal lisp I just mentioned on like this? Right? The 's' and 'z'. Where the tongue is often pushing through the front teeth or against the front teeth. Or it's just too far forward and it's making more of a 'th' sound for 's' or 'z'. 

That's where it's so interesting. Because like my own child is one of my best case studies on frontal lisps. She does not have what sounds like a frontal lisp when she produces 's' and 'z'. Her 's', 'z'. But her tongue is coming forward. And I'm like, "How are you doing that? It drives me nuts." 

[0:30:52] MM: I think that Ð talking about the lingual fillers and those 's' and 'z's'. Because I've had a few of those kiddos where it sounds typical, but then the tongue is interdentalized. And so, just another one of my little soap boxes that I like to bring up, we have to look at the mouth when we give an articulation assessment. We cannot just listen.

[0:31:10] HB: Yes. Thank you. That's one of my big points too. Just because a sound sounds good doesn't mean it's being produced properly. And this is what is so often overlooked or even just dismissed in the SLP community. I've seen people say things like, "Oh, well, they're compensating. It's okay. Because they can make the sound." No. I don't want my child to compensate and use more Ð 

[0:31:28] MM: Why are we teaching a child to compensate? That is a child that we can give them the best quality of life if we allow them to use their oral mechanism the way it was made to be used. Let's stop compensating for children. 

[0:31:42] HB: Thank you. Thank you. I completely 100% agree. Because what we know now is that those compensations snowball into other issues later in life that are already present. It's not just about the speech sound. And so, look, I'm like the first one to say like, "Let's put speech on hold." Because as you said before, in some of these cases, when we go through a myo-type of program, if you will Ð and I don't like calling it a program because it's actually a very individualized therapy. But it's just kind of in my brain, myo program. 

When we go through myo therapy and we address all the root issues at play here and now we've got full range of motion, we've got good control over our articulators, orofacial complex as a whole. Guess what happens? Sometimes these speech sounds self-correct. They don't really self-correct. But they now have the ability to hit all those articulatory targets that maybe they were taught early on but they couldn't physically do yet or didn't have the foundational skills to accomplish yet. 

And so, I think that's what's really cool, is to see those cases where it seems like it spontaneously corrects itself and the parents are like, "Wow." And if it's not starting to happen like maybe halfway through where we feel like we're halfway through therapy or so, we will work on those sounds directly. And we also Ð especially if a family is super motivated by continuing mile. Because they want to address the sounds. Then I'm like, "Let us get through some certain foundational skills. Once we're beyond that, then we can start to like actually tackle these ones in therapy." Anyway. I just wanted to plug that in a little.

[0:32:59] MM: Yeah. No. I think that's awesome. We've covered what we look for in feeding, what we look for in speech. We talked about the respiration and the structure that we're working with. Can you give us some examples of what some goals might look like for a myofunctional program? 

[0:33:19] HB: Absolutely. There are like four main goals usually in a myo program. It depends who you ask. But I typically say it's oral rest posture, bolus prep and swallow, sensation of noxious oral habits and eliminating that tongue thrust. We can dive into each of those a little bit more. 

Correct oral rest posture. At rest, we want tongue up, lips closed, teeth apart. Breathe through your nose. We like that little mantra. We like to repeat that a lot too so that patients remember it. but the tongue should rest fully on the pallet. And so, for many, we find that the tongue rests down or only the tip of the tongue or the front half of the tongue might be resting on the palette. The full tongue, including the back of the tongue. Yes. Everyone goes, "The back even?" I'm like, "Yes." Should be resting on the palette. 

The lips should be together without any tension or compensation in surrounding oral musculature, the mentalis, the orbicularis. Really, just any of those muscles that may be inserting in because we do see tension carry even beyond the face to like the neck and shoulders at times. Our teeth should be slightly apart. About like 2 to 3 millimeters posteriorly between the upper and lower molars. And about four to 6 millimeters anteriorly between our incisors. And we should be nasal breathing. 

Once we kind of address correct oral rest posture or that is something that we tend to address alongside other goals as we're going through myo therapy, we also want to address that bolus prep and swallow through the oral prep and like oral phase of the swallow, right? 

And so, what does that look like? In the oral prep phase, this is the start of our swallow. We're going to place food in our mouth and our tongue is typically then going to control it or it should. By 36 months of age, as I earlier said, we should be using an adult-like rotary chew pattern to break food down and move it across our tongue to one set of molars and back to the other set of molars. And kind of we've now ideally moved beyond just munching and mashing food. We don't want to mash food between our tongue and our palette. We don't want to munch on the back and just kind of go an up-and-down pattern. We want this circular chew pattern happening. But that can be challenging if our tongue is not functioning properly, right? We need to address that. 

And this all happens also while mixing with our saliva to help form a bolus, a cohesive bolus that's then gathered to the center of the tongue ready to swallow. And so that's where like Ð that's the oral prep, right? And then we go into the rest of the oral phase where, okay, we form a bowl with our tongue to hold that bolus in the center of that bowl. It goes up against the pallet. We have that peristaltic movement that pushes the bolus back. The back of the tongue drops down to allow the swallow to initiate and occur. Our tongue also helps to push that bolus backward back towards our throat for swallowing. Swallow is initiated, right? That's a really big component. And I think a lot goes into really the oral phase, bolus prep and swallow, and also establish correct oral rest posture. 

The one thing I want to say about cessation of like noxious oral habits is I didn't define it very well early on. I'll define it real quick. But basically, this can be anything. I mentioned a couple examples like thumb sucking or other oral habits. But we want to look at like is it happening frequently for long periods of time? High-intensity, right? Frequency, intensity and duration. And if it is, that can be indicative of an issue. And if we kind of let it be, this can become more habitual over time. It can also lead to other issues. 

That said, I've actually learned that we wanted to address this before ever starting a myo program. And now that I've been practicing for long time, I disagree with that. Because I actually find that this fixes itself, if you will, in most cases when you address the root cause that led to them first. 

And with a lot of these oral habits, like thumb sucking, for example. If you put your thumb in your mouth and you suck your thumb, you're actually going to feel that your lower jaw adjusts forward. What happens when we bring our jaw forward, our lower jaw forward, our mandible, we're open opening our airway. 

I never actually want to take away a habit that might actually be serving a biological need until I know for sure that, one, it's safe to do that. And, two, I have something to replace it with. And so, for me, the replacement is actually correcting the oral rest posture. Making sure they can nasal breathe. Working on that bolus prep and swallow. Because as we do that, we find that the need for those oral habits decrease on their own. And that's just the easiest way in my opinion to accomplish eliminating that. 

[0:37:26] MM: That's awesome.

[0:37:27] HB: Yeah. And then eliminating tongue thrust. I think when I went through grad school, tongue thrust to me just was like a speech sound disorder. And actually, I was taught that it was normal to have a tongue thrust until like a certain age. And you didn't even have to address it until age five, or seven, or whatever. Everyone has different opinions, right? 

I now know tongue thrusts are never a normal thing in speech feeding, at rest, whatever. And in order to do this, I teach in our myo therapy what I call muscle-informed exercises. We need to know where the deficit exists. What is the root cause of what's going on that's leading to maybe a low, forward tongue posture at rest or during the swallow? 

And truly, the components of the myofunctional therapy program addresses as we teach the tongue where to rest in the mouth and where to exist when prepping a bolus. And how to function and basically coexist with the rest of the oral facial complex, right? And oral phase of the swallow. 

And so, SLPs can take this one step further to address like any impacted speech sounds like we were talking about. If they don't correct during the course of the myotherapy, awesome. Address them directly, right? But like we were talking about, it's often with much greater ease. And the tongue and orofacial complex needs the ability and full capacity to function as it's supposed to, like optimally, right? 

Once we give it that ability, it's much easier to correct these sounds and to correct where the tongue exists during the swallow, which is part of myofunctional therapy. Truly, eliminating a tongue thrust is basically graduating from a myofunctional therapy program. 

[0:38:53] MM: Right. Yeah. That is fabulous. And so, if you feel comfortable talking about it, I did a live episode with Christy Gado and we got a lot of questions of, "So, you're using exercises." And so, you use muscle-informed exercises. Would you feel comfortable kind of going into a little bit about like what a muscle-informed exercise is in a myofunctional program?

[0:39:12] HB: Yeah. I'll give a couple examples, right? Let's just use a patient as an example. And this is going to be super specific to the patient and how they presented not just during their eval, but during their first session. Because we may probe things that we saw in the eval. And sometimes I like people to remember that if you're asking somebody to do something for the first time that they've never done before and that their tongue, or their lips, or their mouth is not used to doing, it may not be that they can't do it. It may just be that like they're not processing how to do it yet and they just need some practice or exposure to it first, right? 

I like to go back and probe anything I found in the eval during our first session. And then from there, let's say we have a seven-year-old who is still munch chewing. And they're using their tongue and jaw together as one unit. They haven't dissociated anything. Everything's just kind of moving around together. If it's not the first session, we always like review homework first and everything. But like if it's the first session in this case with this child who does not have much lingual control, we might start with lingual protrusion. Because if this child has demonstrated to us that when they stick their tongue out, it goes out and down as like you demonstrated earlier. 

And it's so common with OMDs that the tongue goes out and down. We want them to have the control and the ability to stick their tongue straight out. Now, look, I know there are not that many things in life that require us to stick our tongue out straight. But it is a skill, a baseline skill, if you will, a foundational skill that we should have. And we should be able to do it without the help of our jaw. We should be able to do it independently. 

Same thing goes for retracting the tongue. We might work on that. Same thing goes for lateralizing left and right. We'll take the tip of our tongue and lateralize it to the corner of our mouth on one side and then to the corner of our mouth on the other side. And we're doing this all while stabilizing the jaw to help the tongue learn to function independently of the jaw while engaging in these movements, right? 

Next after that, we might address lingual elevation and depression. And like we talked about before, getting initially just the tip of the tongue up to the alveolar ridge. Can we even do it? Do we have to close our mouth a little bit so that we don't have other compensations at play because the tongue is restricted? Or have we just really never done this before? And so, this is new. And so, we just have to kind of task analyze and work a little bit on going, "Oh, okay. I'll take like a coffee straw, for example, and I'll touch the tip of the tongue and then I'll touch the spot." And I'll go Ð what I touched on your tongue up to where I touched on the top on the roof of your mouth. Oh, good. 

Or we'll use food sometimes or whatever. Anything to just kind of help that functional skill become something that they start to program into their brain, right? We call this neuromuscular re-education. We're basically teaching you and your brain where your tongue should exist and how to Ð when we're task-analyzing much larger skills that we use on a regular basis back down to their basics, right? We need these foundational skills. And then we eventually will pull a lot of these skills back together into more functional tasks like speaking, and bolus prep, and the chew, and swallow, and all that. 

With like lingual elevation, we may even start with just, "Can we get the tongue up to the spot?" We call it the spot. Up on the alveolar ridge for five seconds. Can we do it for 10 seconds? 15? 30? Great. Now can you hold that for 60 seconds? And that may not happen in one session. That may take a couple of sessions to accomplish. 

And we start to teach them. There's a lot of Education involved where we start to teach, "Hey, this is where the tip of our tongue lives. Oh, great. Now that we got the tip up there, let's focus on getting more of the tongue up there. Can we get the whole tongue up there?" And if they're restricted, we know that's not happening. How much of the tongue can we get up there? 

And it's really interesting too because you'll see children gag. You'll see these very hyperactive responses to the tongue on the pallet because they've never had the tongue up there. Or maybe they're thumb-suckers. And so, they're used to having something up there because that thumb has been filling that void. And now we're going, "You know what? Your thumb doesn't really need to do that anymore. I'm going to teach you how to help use your tongue to fill that void and basically fill the same purpose of what you're doing with your thumb." 

And so, once we start to accomplish that, we can start, like I said, to elevate the full body of the tongue up to rest on the pallet. But as I mentioned, we do have to like task analyze, right? Because these other smaller movements exist in speech, and bolus prep and swallowing. And it requires us to be able to do them individually before we can pull them back together and really truly help that tongue function independently of the jaw, the lips, the rest of the face. 

At times, we'll have to stabilize the jaw. We might use a bite block or something similar just to kind of get that jaw to stabilize and stay in one position so the tongue has the opportunity to start moving without the jaw moving along and following it, right? And this could be very challenging for some patients. Because they've never done this. And so, it doesn't feel weird. But it's kind of like, "Yeah, my jaw won't let me do that. It just wants to go with it." Right? 

I've had some individuals who I'll say, "Okay, let's put the tip of our tongue right here in the corner of our lips." And as they do that, their entire neck starts to turn or their shoulders starts to turn Ð these full body movements because they've been compensating for so long and they don't have the capacity or ability yet to do some of these exercises. 

But the reason why I call them muscle-informed is because I go back to the evaluation. And I do believe that every session is a mini evaluation in and of itself. It's dynamic therapy. Are you functioning today? What can you do this week that you couldn't do last week or a session? Not necessarily a week. And what do we need to work on? What is the next step in getting you to these more functional tasks? That we need to know what we're trying to accomplish. 

And so, I share this because there's a lot of people who will teach myo in 12-week programs and they give everybody the same exercises. And it's like, "This week, you get these three exercises. And next week you get those four. And you're going to do this as many times." And I'm going, "No. I don't know how many reps I want you to do until you're sitting in front of me and I see how you're doing it." 

And guess what? If you haven't accomplished it successfully with me, in front of me, I don't want you working on it at home because you're just going to compensate more. And that's not going to help us. Let's work on the things that you did really well, really successfully in our session. Carry that over at home. Come back next week. We're going to see what happens. Sometimes other skills are gained by working on some of these other foundational skills too.

And so, these whole like prescribed, like, "First, you do this. And then you do that." No. I think we need to know what's going on with the muscles. We need to know what's happening on the face. We need to be able to look and go, "Okay, the whole jaw is moving. Let's stabilize it. Give them the opportunity to learn how to move that tongue independently." Once we do that, then we can start to build on some of these other skills as well. I don't know if I answered your question. But, hopefully. 

[0:45:22] MM: Yeah. No. I think that was perfect. Because I think that you really had the nail on the head. We are doing these muscle-informed exercises. But once again, we're not just doing a side-to-side motion and calling it good and moving on. We're really looking at the quality of that skill and we're doing it for a purpose. Jaw stabilization, tongue coordination, improving a weak muscle that they have so that they can transfer that over to a functional skill. 

And I think the other really big thing with myofunctional therapy that you also touched on is that we're doing this foundational skill that's going to carry over to that functional feeding or speech-related task or rest posture task that's going to improve their breathing. 

And so, it's not just an exercise for the sake of doing an exercise. It is an exercise with an explicit purpose that's going to lead to a functional improvement. Because our tongue, and our jaws, and our cheeks are made of muscles.

[0:46:18] HB: Yes. Exactly. Right? It's amazing how the body works. I mean, it's a little frustrating sometimes too because you do get like SLPs and people who are in our specific field that just go, "That's just not a thing. Tongue-ties aren't real." And we're going, "So you're discounting all of our experiences?" And there is maybe little research on some these. There's not a ton. But it's real. It happens. 

And, personally, I'm like, "If this were to put me out of business because people spend less time in therapy, I feel like my job here is done." If we can Ð whether it's an infant who's struggling to feed with tethered oral tissues or it's a myofunctional disorder at play with a child who's a bit older. And we do see myo in babies too. We just use a very different assessment and treatment approach. Discounting it I think is scary almost because it's a big spread of misinformation. And we don't have to go there. 

But I wanted to mention that because I think people will encounter that they're going to be like, "Well, what about all these other people who say like it's not a thing?" It is a thing. Myo is 117 years old. It's not new, people.

[0:47:11] MM: Yeah. The first episode that we did with Linda, she really dove into a lot of the research. We talked about all the level articles that support myofunctional therapy. It is so real. It is well-supported. And then the other thing is evidence-based practice includes research, clinician experience. And I think within clinician experience includes how we're critically thinking. I can think critically about the anatomy and physiology of the cranial facial complex. And I absolutely will apply that to what I'm treating. 

Clinical experience. And then, three, your patient values. If you have a patient that wants to do myo, they understand the importance of myo because they've done their own research. And I know in my clinic we have a lot of people that pick up the phone and say, "My child has a myofunctional disorder. They have a tongue tie. I've had people tell me no, but I know in my gut this is what they need." And they come in and we make progress. And so, this is an evidence-based practice.

[0:48:02] HB: Yeah. And my hope is just that more clinicians also start to recognize some of the signs or symptoms that like we commonly see that may even say, "Hmm. I think I should look at this a little bit further." Right? The kids who Ð for example, like in little kids or even adults too, we see that mouth open posture with the lips apart. You can see the tongue low and forward. You can see the mouth breathing, right? You can see maybe a forward swallow posture if their tongue is thrusting between their teeth and their face is really messing. The food's falling everywhere. 

In pediatrics especially, we see picky eating. We see drooling that doesn't seem to get under control. Whereas with adults, they'll have unresolved sleep issues, and neck pain, and migraines, and TMJD, and just a host of other chronic issues that are connected. And I think like if we can start to realize that these issues are very visible to the human eye and you're already working with these patients or screening or assessing, yeah. If something in your gut is telling you, "Oh, hey. Maybe I should send them for a myo eval." Do it. Nothing bad is going to come out of it. If anything, you're going to help them in ways that they didn't know were possible. Because a lot of patients are not as familiar Ð a lot of speech pathologists are not as familiar yet. It's really educating our own so that we can then educate the public. And I do think we've made big progress towards that. Because we do have a lot of patients coming and requesting myo evals now. 

[0:49:14] MM: Right. And the other thing that I think Ð just to kind of change the way that speech pathologists might be thinking about this. The way our clinic functions within my community is we work really closely with other speech clinics in our area. And so, we share a patient. We will get a referral for another patient for their feeding disorder or for their speech sound disorder. But they also have language. 

And so, we will just cover the myofunctional piece, or the feeding piece, or if they need support on the speech piece. And so, we share that patient. We can both see them. We can both build speech as long as it's on another day. We're working on different targets and things like that. And so, just because you refer out doesn't mean that you have to lose that patient. You can form like a team with the myofunctional therapist that you're working in conjunction with. 

[0:49:59] HB: Yeah. Well, and arguably, my practice does Ð while we do all of the above because we have people who specialize in different things, we do have people who refer to us who are working with a child on speech or language and they'll refer to us for myo or feeding. 

And because they refer to us, we refer them back. Even though like Ð can do these things, well, that's not nice. I'm not going to go steal your patient from you. We're going to do what you sent them to us for. And then we're going to say, "Okay, they're either co-treating. Not maybe in the same session. But they're treating that patient for that once a week. They're seeing us for myo once a week." We can coexist. There doesn't have to be any sense of competition, if you will.

I think this competition is just so evil. It's really about the patience. That's why so many of us get into this profession in the first place, is we want to help people. This is a helping profession. And so, I think if we could just kind of put the patience first and remember why we do this in the beginning. Like you said, critical thinking is a huge part of it. But what can I do that's safe? That's effective? That does have research to back it that will actually help my patient move the needle forward today? That's kind of the question that I always ask. 

And look, who knows? 20 years from now maybe something else will come along and we'll be like, "Oh, wow. Myo was awesome. But this is even better." I don't know. I mean, like I said, myo's been around for 117 years. I'm not downplaying it at all. But I also think that having the mind of somebody who's a lifelong learner and who's open to new information is the best type of clinician. Because that's Ð you're going to need the best for your patients.

[0:51:21] MM: Absolutely. I love that. Because even the field of myo has changed a lot. And so, just like keeping up in staying current on research, and learning more and always looking for the next best thing for your patient. Yeah, that's super great. 

We just have a couple more minutes, but there's been a lot of talk about babies. If we could just maybe briefly touch myo isn't appropriate for those under four. But how can we take that myofunctional lens and apply that to the under-four population? Because I know we're going to get a lot of questions about that. 

[0:51:53] HB: Absolutely. One of the reasons I say that is because, in the myo space, there are other professionals who are not licensed to work with infants, toddlers or do feeding who can do myo. And that's kind of a funny thing to say because there is the oral phase component of myo therapy, right? 

And so, if you have like an RDH, or a dental person, or a PT who maybe doesn't have feeding training or whatever, right? Who can do myo but maybe they're not doing ped feeding, it really falls under the scope of an SLP or an OT. I am not saying that myo is not for infants and toddlers as a blanket statement. I'm saying myo in its traditional form as an assessment and treatment program is not appropriate for a child or an adult even who has less than a four-year-old cognitive age. 

And so, what would happen if you do get an infant and a toddler? Well, we're not going to wait. I am not saying wait. And this is actually why I created my Feed The Peds course. Because I was like, "Well, I don't see anybody really talking about this or teaching this. How do we address tethered oral issues? How do we address mouth breathing? How do we address Ð they don't have proper oral rest posture. And that's probably connect connected to why they're struggling to breast and bottle feed. 

And, okay. Oh, wow. This is actually what we already do in our assessments and our evaluations, but we just need to frame it differently and also maybe pull in some different providers to help address some of the issues at play and the root causes behind this. 

In my course, I have a 12-week feeding course, and in that course I actually Ð the only modules I teach are module seven, which is tethered oral tissues. And module eight, which is OMDs, orofacial myofunctional disorders. And how to adapt what we know from these areas to the infant, toddler, preschool population. Ultimately, birth to five is like what we really talk about in there. 

And I think the case studies really give good examples of how these symptoms that we've talked about today do exist in those younger populations. And then how we assess them and treat them through the lens of a sensory oral motor feeding assessment and treatment program? Does that help answer a bit? 

[0:53:46] MM: Yeah, I think it's perfect. A lot of times, that shows up in those feeding disorders. And so, if we once again take that very physiological approach to what is happening in the oral phase of feeding, what needs to happen? And then we use feeding skills and we develop those feeding skills to a more typical correct pattern of feeding, then we're going to kind of be doing that myo lens of feeding for those age groups. Yeah. 

[0:54:12] HB: Well, I do have like both Ð I have two free screeners. One is a pediatric feeding screener and one is a myo screener. I call it the F.A.S.T. Myo Screener. And they both have symptom checklists. And so, it goes over like the top 50 symptoms we see in pediatric feeding cases and then also the top 40 symptoms we see in myo cases for those kids and adults. 

And I think that really helps to also delineate between, "Oh, hey. These symptoms do exist in both populations." It's just, again, how we're assessing and how we're treating that changes and know we should not be waiting. And, yes, we should be getting involved as early as we possibly can to put that child on the right trajectory for correct oral rest posture, and oral phase feeding, and swallowing, and all the above, which falls under myo. Right.

[0:54:54] MM: A speech pathologist that's listening that hasn't had formal myo training, well, I think you said you could give the myo screener? Could you also send the PFD screener? And we can put those in the resources on the course module page if that's okay with you.

[0:55:08] HB: Yeah. 

[0:55:09] MM: I know we kind of covered it, but can we just like real quick blanket statement? List out the signs and symptoms of these like myofunctional disorders so that clinicians that might not have that myofunctional training can be like, "Okay, these are the things that I know that I see. And I need to find somebody that I can refer out to." 

[0:55:25] HB: Yes. I will give you that quick list. Abnormal oral rest posture, right? Mouth open, tongue low and forward. Mouth breathing. Tethered oral tissues. Atypical swallow pattern or that forward swallow posture that we talked about, like a tongue thrust, right? Picky eating, limited foods accepted, nutritional issues, drooling, noxious oral habits like we talked about, articulation issues, dental issues. Is there malocclusion? Are there TMJ issues? Gum disease? Orthodontic relapse? Halitosis? High-narrow pallet? Airway issues? Snoring? Noisy breathing? Congestion? Mouth breathing? Sleep issues are a big one. Nocturnal enuresis or bed wetting. Changes in physical appearance like a long narrow face and other Ð bags under the eyes? All kinds of other symptoms that we may see on the face. 

Emotional issues, behavioral challenges, struggles at school or like ADHD-like presentation can be tied to this as well because of a lot of sleep issues and breathing issues. And then we also talked about postural issues, like neck pain, and migraines and things. That's just a whole quick list of signs and symptoms. 

[0:56:25] MM: And then the other thing is what happens if there is a speech pathologist in an area where there's not a myofunctional therapist to refer out to and they might not have the money to go and spend a lot on a full 28-hour myofunctional course? What would be some good resources for them to start off on if they kind of need to take this into their own hands to figure out how to kind of support these kiddos or adults?

[0:56:50] HB: Oh, that's always like the age-old question, right? There are textbooks if you want to read. Hansen and Mason have a textbook, which I think I gave you the link for this episode. So that should be connected somewhere hopefully if you guys Ð 

[0:57:02] MM: Yeah. We have it in the reference list. 

[0:57:04] HB: Or I am creating Ð everyone is basically like, "Okay. Great, Hallie. You've done this free training for your pediatric feeding screening packet. Can you do one for the myo packet too so we know how to screen and we know what these signs and symptoms mean and all that?" 

And so, I'm actually creating a free training that will go over how to use the F.A.S.T. Myo Screener. That'll be available soon like probably in a couple of weeks. It's created. We just have to get it out there. That can be a good step forward. I do have my membership, which is pretty low-cost on a monthly basis. And so, that is a place to dive in and learn. You can learn how to evaluate in there. You can also just learn about all different topics related to myo, airway, tethered oral tissues and stuff. Podcasts like this or like my Untethered Podcast. 

I think it's challenging because I don't know the quality of a lot of other resources that are out there. While you may like ask AI or go Google things and Google pops things up for you, it's like I can't promise the quality is going to be good. But I at least know the quality of what I've listed. Hopefully, that's a lower-cost or free place to jump off with.

[0:58:03] MM: I think that's great. And it gives people just a place to kind of get started. And so, could you just go over really quick what a child that's been established or an adult that's been established in a myofunctional program what a typical treatment session would look like? 

[0:58:16] HB: Sure. Going back to the example of like the seven-year-old, right? Let's say that Ð it's going to depend on what are our goals. How are they presenting today? But let's say he's starting out and he does not have that great lingual mandibular dissociation. We're going to start to work on stabilizing the jaw. 

And I like to start with the jaw, especially in the beginning of whether it's feeding or my, honestly. I think jaw stabilization is so important because we have to teach the tongue and the lips to coexist or to exist without support of the jaw fully, right? And so, in order to work towards that rotary chew and move away from like a Munch chew and help the tongue work independently for speech production and all that fun stuff. 

We'll stabilize a jaw, whether it's with a bite block or however we choose to do it. And start to work on maybe protruding the tongue, retracting the tongue. Well, maybe some lateralization. And I'll see, like, can we do tongue clicks? Can we get the tongue 'ng'? A lot of people all try and work on lingual palatal section. They're just like, "I don't get what you're asking me to do. How do I do this?" 

And so, we're like, "Okay, can you click your tongue? Can you do a click?" And they'll be like Ð and they'll move their entire jaw and tongue, right? And so, I'll be like, "Okay. Well, we're going to call that a cluck or a clack. But we wanted do a click, right?" I just kind of like to differentiate it so in the brain it processes different things. 

And so, I'm like, "Great. Clack. Let's do a click though." I was like, "Let's relax everything and see if we can kind of just like gently do a click and release our tongue. And, okay. Great. Now that we can do that, can we do that again but like keep our tongue up there? Don't let it fall down." 

And so, working towards that lingual palatal suction is super important and getting that like lingual jaw. Tongue differentiation is also super important, especially if you're like leading up to a tongue-tie release or frenectomy. We want good lingual control. We want Ð even if there's restriction, and we know there's compensations at play, we're going to try and reduce that as much as possible leading up to the release. 

And so, we often will work a lot on lingual mandibular dissociation, range of motion activities. Getting the tongue to narrow and widen. Creating a bowl if we can. Elevating, depressing the tongue. I think I already said protruding, retracting. All those tongue exercises if you will. 

But then we'll also work on the lips. Can the lips close? Can we retract the lips? Can we round the lips? I could sit here and just list off like a whole bunch of exercises. But the idea is like, again, we're looking towards function. And what are we needing to do today? And what is the baseline thing, foundational skill that we need to address right now to get us to the next step? 

Because at a certain point, once we can do all these foundational skills, a later session might look like, "Okay, we're going to pull these skills together. I'm actually going to bring in food. I want to see how you chew that cracker. I want to see how you chew that grilled chicken. I want to see how Ð okay. Great. Show me your bolus. Stick your tongue out. Let me see how it looks on your tongue. Oh, no. All right. That cracker spread all over the tongue. We still got work to do. We got to teach that tongue and that jaw to work together and pull that bolus into a cohesive ball in the center of the tongue that's ready to swallow instead of being spread all over, right? And then how many cleanup swallows do we need? And we should not be washing down with liquid washes. 

And so, it's going to depend on where you are in the program. But, again, it's going back to function and functional skills. And what are we still needing to address to achieve the goals of may? 

[1:01:26] MM: Perfect. Well, thank you so much for your time today, Hallie. This was so helpful. It gave us a really great rundown of what a myofunctional evaluation is. Why we need to look for them? The signs and symptoms. When we should refer out if we don't know how to do myofunctional evaluation? It was great. I appreciate it so much. And I know all of our listeners will too. Thank you so much for attending today. We will see you next time. 

[OUTRO]

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SLPL S11E5
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