SEASON 11 EPISODE 9

[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 guest, 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.

[OVERVIEW] 

[0:01:03] MM: Hello. Welcome to another episode of the SpeechTherapyPD.com miniseries, Making Sense of Myo. My name is Madi Metcalf and I'll be your host for today. On today's episode, we'll hear from Melissa Vagts who shares how understanding orofacial myofunction is a tool for differential diagnosis. We'll talk about some individuals who this might not be an appropriate treatment plan for, and how we can modify that approach to still treat speech and feeding disorders.

As a reminder, this is part of a series, so if you're a little confused on what an orofacial myofunctional disorder is, or how it impacts speech, or feeding, feel free to go back and listen to some of the previous episodes. Before we get started. Just a couple of reminders to alert you to, this episode of 60 minutes and we offer it for 0.1 ASHA CEUs. To get credit for the course, make sure that you go on to the Course Planning page and complete all the modules including the quiz.

[DISCLOSURE]

[0:01:56] MM: I'm the host this podcast and receive an honorarium from SpeechTherapyPD.com for hosting. I do not have any relevant non-financial disclosures. Melissa receives a compensation for this presentation from SpeechTherapyPD.com, and she's an employee at Wichita State University. She does not have any relevant non-financial disclosures.

[EPISODE]

[0:02:15] MM: Now, without further ado, we welcome our presenter Melissa. Melissa Vagts, MSP, CCC-SLP is a certified speech-language pathologist who is currently an associate clinical professor at Wichita State University in Wichita, Kansas. She received her master's degree from the University of South Carolina. Melissa has 25 years experience working with pediatric clients in outpatient clinical settings, public schools, and university clinics. Melissa currently teaches and supervises CSD-MASLP graduate students focusing on early intervention speech, sound disorders, pediatric feeding, and orofacial myofunctional disorders.

In 2022, she developed an orofacial myofunctional disorders graduate-level course, which she teaches each summer at Wichita State University. Melissa also co-developed a pediatric feeding group in 2019 at Wichita State University to provide SLP graduate students with hands-on learning opportunities. Melissa is passionate about educating students and other SLPs on how OMDs affect feeding and speech development in children. She has obtained a variety of CEUs and training in the areas of pediatric feeding, tethered oral tissues, and OMDs. Welcome, Melissa. I'm so excited to have you on the podcast today.

[0:03:28] MV: Thank you so much for having me. I'm really honored to be here. Myo functional therapy has become my passion over the past four years, and I love teaching it to the graduate students at Wichita State and incorporating it with my clients at our Speech Language Hearing Clinic. So, thank you for having me, and it's been so exciting to listen to the podcast so far. It's amazing, and you've had such amazing speakers, and I'm learning along the way too, as I go listening to them. So, thank you again.

[0:03:58] MM: Thank you so much for those kind words. I'm so happy to hear that people are benefiting from the podcast. Also, I love the fact that you have made a myofunctional course at Wichita State University and that you are spreading the good news to the up-and-coming SLPs that are going to be coming out into the field. That is amazing, and I am a little jealous that I didn't get to take that course myself.

[0:04:23] MV: Thank you. Thank you. We've had some people reach out and say, ÒHey, can I just sit in on it? Because I didn't have that in my grad program.Ó So, it's really exciting and I'm really grateful to our university that they allowed me to develop that program for the students it's really such a benefit, and they're able to see their clients in a different way after going through that course.

[0:04:43] MM: Oh, my gosh. So awesome. Just like a little review for people that have listened, we're going to start off with like what is a myofunctional program? Do you want to give us a little overview about what OMDs are really quick, and like what a myofunctional program, just like real quick overview of it?

[0:05:01] MV: Like a lot of your speakers have said, if people go back and listen, they'll get a lot of great information. But orofacial myofunctional disorders, anything that's affecting the oral facial myofunctional complex, so our face, and our mouth, basically. So, things that could kind of go awry, that could possibly impact their overall either facial development, their dentition, their speech, their swallowing, their feeding, their sleep, their breathing. There's a lot that goes into it. 

So, we can implement certain strategies or therapy techniques to help people who are having some issues with their myofunctional complex. So, qualifications for participating in a program, basically. So, I use a lot of information from Robyn Merkel-Walsh, and Lori Overland. They came up with some great information, I believe it was 2020, and I think I took their course and maybe 2021. But basically, they state that for a true myofunctional therapy program, the individual needs to be at a cognitive age of four years or older. So, we really want to think about that, in that way, because a myofunctional program is very sequentially based, and you have to be able to follow directions, and kind of understand what is being asked of you, and imitate those oral movements.

When you think about that, there's maybe a lot of people we might work with, a lot of clients that might not fit that bill, and that's okay. Also, I wanted to mention, Hallie Bulkin also talks about this in her Maya method course, and her feed the peds course, which I've taken both and they're amazing if you're interested in this part of our field. But a client, and I use the word client, because that's what we say at our clinic. So, you could say a patient, a client, whatever you want to say, but they need to have awareness, kind of what's going on structurally with them. Ability to participate in the program, like I just talked about. Following directions, understanding what's being asked of them, and then they also need either family support, or to have that buy-in, to really want to help themselves through this process.

So, for best outcomes, families, and patients should be willing to practice at home. There's a home program that's usually involved in myofunctional therapy, and they have to be willing and ready to participate. If they're not, then we may give them just some ideas of things they can do. But we may need to work on some other things until they are ready or until they see the value in what we're doing.

[0:07:36] MM: So, just because the patient is like four, five, or six years old, or maybe even older, 11, or 12, does that mean that they might still not be appropriate for a myofunctional program, even if they are at that age, like over that four-year-old age?

[0:07:51] MV: Correct. And age is just a number for this, so some of our special needs clients may not be a perfect fit or a great fit for a true myofunctional therapy program. That's kind of what we want to talk about a little bit today is what if they are cognitively functioning lower than a four-year-old, or they have some special needs, or they are a two or three-year-old and thatÕs their age. We can provide some intervention for them to help them also. But it would just be Ð it would look a little different. We wouldn't call it myofunctional therapy. So, a lot of this is what you're labeling what you're doing.

So, it wouldn't be a myofunctional therapy program. But it could be a pre-feeding program, that's something that we can look into. It can be a sensory-motor program. So, those are the differences that we want to think about. If anyone's interested in learning more about that, there's a book out there by Walsh and Overland, really talking about the sensory-motor aspects of feeding and intervention. All of that helps me make that decision, or to decide what's best for the clients.

[0:08:57] MM: Awesome. So, if we're not going to use a true myofunctional approach, how can this knowledge of orofacial myology support differential diagnosis for figuring out, is there an underlying motor problem impacting speech and feeding? Or do they need a mild functional program? Or do I kind of use some of these ideas from myo to help support and develop some of these other skills?

[0:09:22] MV: Yes, all of that. But we can implement not necessarily the sequential program, but we can help our clients establish kind of that patent nasal airway. So, through their nose. We can establish that nasal breathing. We can help decrease the noxious oral habits with thumb sucking or finger sucking. We can also look at them in a way to be able to refer them to other specialists. So, an ENT is super important. If a client has large tonsils, adenoids, or is a mouth breather, has allergies all the time, and never breathe through their nose. We can also refer to an airway-centric pediatric dentist or orthodontist who has the training and the knowledge in those underlying issues that affect dentition, and breathing, and speech, and swallowing.

Sometimes a sleep specialist may be necessary to help kids or individuals in general. I taught kids mostly because that's my focus. But this also applies to adults. We also teach proper positioning of articulators as well. So, that typical oral rest posture. We can do that with basically, I would say, two-and-a-half-year-olds and up, and I've done that in my sessions with a client that might just be there for articulation. But I'm noticing that they are a mouth breather all the time. They cannot close their lips and breathe through their nose. They suck their thumb.

So, what are some things I can do to help with that? Because I know that eventually could affect their overall facial development, as well as their ability to say speech sounds correctly in the future, and it could also be impacting their feeding. A lot of these kids do come, and they're coming for me for articulation, but their parents are like, ÒYes, they're a picky eater.Ó So, I also hear that and think, ÒHmm, maybe I need to look a little further also, because there's several different things.Ó

But with your question with differential diagnosis. So, what is differential diagnosis? I looked it up and Oxford Dictionary says, ÒIt's the process of differentiating between two or more conditions, which share similar signs or symptoms.Ó Well, we do a lot of that in our field as speech-language pathologist. ThereÕs an overlap with things. So, it is crucial that we understand kind of what we're looking at with each client, and treat them as individuals, and figure out what's going on with them so we can help them in the best way that we can as their therapist. 

For me, it means I'm doing all that I can using evidence-based practice, including research that's out there, as well as practice-based evidence. So, a lot of people are doing this. They are clinically relevant in sharing their knowledge of some strategies and things to do. I think that's important. I also use my own clinical experience and what's worked and what's not worked with my clients. Then also, the client input. What's important for the client as well as the family? And what do they want to get more support or help with?

Sometimes I'm the one that brings up something with sleep, or breathing, or tongue tie, and then they need to think about it a while, or I need to provide a lot of education and information. Then, sometimes they're ready to pursue something further, and sometimes they're not. That's up to the client. We have to be respectful of that, for sure.

[0:12:40] MM: What do you do whenever you see this airway concern, or a myofunctional concern, or tongue tie, or the need for palate expansion, and the family just isn't ready to take that step? How do you address that in your practice? I know that's kind of a loaded, hot question. But this is something that I'm kind of learning to navigate in my own practice as well right now.

[0:13:03] MV: I feel that a comprehensive orofacial exam is one of the most important things that we can do as a speech-language pathologist, as well as getting a really great detailed case history from the family. So, if they're just coming in for an evaluation, it's your first visit with them, then I will look over everything in the case history, kind of look at what it's leading me to think is going on. Then, when they come in, I'm going to watch, observe, and listen for the entire time they're with me. So, I teach that to the graduate students at Wichita State, IÕm like, ÒYou are constantly observing and watching and writing down, and you are constantly asking why. Why are they doing this? Why are they not able to do this?Ó And you're asking why to figure it out. It's like a puzzle.

But I'm going to do that orofacial myofunctional exam, and I'm going to look at their structures in a very detailed way. I also do a tethered oral tissue screening, but for my orofacial facial exam, I use Amy Graham's Oral-Facial Exam that came out.

[0:14:09] MM: ThatÕs a great orofacial exam.

[0:14:11] MV: Very detailed. You can go online and purchase it. It's very detailed. It covers all the areas that I really want to dive into. But it also gives an explanation of what each area, like why you're looking at it, and what it's all about, which for me, is great for showing the graduate students, because that's what I want them to have, a way to learn and to teach them that.

I also do a tethered oral tissue screening on my pediatric clients, and I use Autumn Reed HenningÕs protocol for that, because I took her TOTS course, and it is amazing. So, I do those things automatically in my evaluations, as well as doing an articulation assessment, or a feeding assessment. If I'm not doing feeding, I might have them eat or drink something, just to watch how they're eating, if I'm not doing a full feeding evaluation. I'm taking a language sample, I'm listening for their intelligibility. Because some kids will have articulation sounds that are almost perfect. But then, in that connected speech, there's a huge breakdown, and sometimes it's due to fatigue, and where they do have restriction, tethered oral tissue restrictions, or there's something going on where they just can't move their tongue in a way for those precise, fine motor, quick movements, that happens when we're speaking. So, they're fatiguing, or they're mumbling more. They just can't get it out clearly.

But I am constantly looking at their face, listening to what's going on, and try to make that decision for that differential diagnosis. But if a parent is not on board, that's okay. So, what I do during that evaluation is I will provide as much information as I can, and really apply it to what I'm seeing. So, I'm noticing a potential tethered oral tissue or restriction, lingual restriction, and I will maybe mention that. I'll show it to the parent, and then I'll tell them why I have a concern, or what it may impact. So, it's very important that we educate as much as we can, but you've got to have training in this to be able to do that effect.

But you got to know what you're looking at within the mouth and the face, and then be able to talk to the parent, the caregiver, or even the client about it, specifically. Then, you just let them kind of think about it, and sometimes they are ready and willing to either work with you for a little bit, and then maybe consult an ENT, or a dentist for a tongue tie release. Sometimes they're not ready. So, you work with where they are and we can still do things to help them. So, thatÕs a long answer for that question. But it really is something you have to know what you're looking at, and then be able to explain it and educate the family, or the parent, or the client.

[0:16:57] MM: Yes. I love hitting on that education piece. Because so many times I find in my clinic, these parents don't realize that so many things can be related to one another. Or that the fact that they're not sleeping, actually, is impacting maybe that their tongue is like, protruding out forward, or they have a bad gag reflex, or a difficult time swallowing, or moving food around their mouth, and things like that. Because if the tonsils are really enlarged, and it's sitting on the back of the tongue, that can just cause a lot of problems, and all the sleep things theyÕre experiencing.

[0:17:28] MV: Yes. To differentially diagnose, it comes from several things. ItÕs not one test. ItÕs not one thing that you look at. You have to be able to look at a variety of things to really tease it out, and make your best kind of judgment. Sometimes itÕs a best guess at first, until you get them into therapy, and I'm constantly modifying and adjusting what IÕm doing once they get into therapy, because I'm not always right. That's okay. And then evaluation is like an hour, sometimes, or an hour-and-a-half in this person's life. That's it.

So, when they start for therapy, you're going to start to see other things maybe that you missed, weren't even aware of in the evaluation. So, I modify. I pivot a lot to make it work for the client. Don't just stay in one lane and do one thing, because that's what I think I'm supposed to do, because I found that they are having trouble saying L on the articulation test. But they can't even move their tongue up to the alveolar ridge. Like, ÒOkay, I need to backtrack and figure that out.Ó

It's important to ask the whys and to constantly change and figure it out. So, for me, for where I work, most of my clients come in for articulation, language, or feeding. They're not coming in because they already know or think they have an orofacial myofunctional disorder. That's not my true focus yet in our clinic. So, I really have to use that diagnosis piece, and figure it out, and tease it out, because they're not coming to me for any of those issues. I'm the one that usually, may find them for them, but they're not coming to meet me for that.

So, I really need to look for those signs and those symptoms, and I also need to know how to write those in a report. An evaluation report, so that I can share this information if I feel like they may need to go to another specialist. For young children or just pediatric clients, they're getting their pediatrician, usually, is the one referring them, and this is a great way to educate the pediatrician as well on what we're seeing, and what it impacts, and why we're thinking that they may need to go to the dentist or the sleep specialist, or an ENT, or an allergist, or whatever it may be. But we really need to look at every client through that comprehensive lens and ask that why to find the root cause of the issue, and that to me, is the most important thing that we can do as speech-language pathologist. Because that kind of gives us a place to start and then it helps us move forward as well.

I will, maybe, start seeing a client and they're not making the progress that I think they should make. So maybe, I wasn't really thinking there was anything maybe underlying there with orofacial myofunctional disorders, and they're just not making progress. Well, that's a red flag for me. So, I will go back and do another orofacial exam, usually. I try to figure out what did I miss, or what's going on, that's causing them maybe to not make this progress. So, I feel like sometimes your pride gets in the way as an SLP, that you didn't get it right the first time. It's okay. You modify it, because it's really what's best for the patient and the client, for sure.

[0:20:38] MM: I love that so much. It's one of the things that I tell my graduate clinicians that I supervise, is that in your initial evaluation, you don't have to have it all figured out. That's all it is. It is your initial evaluation. One of the things that I've really come to rely on is every time I lay eyes on my patient, it's like a mini reassessment. I'm constantly using that dynamic assessment to check in, see if we're making progress, looking for something that might have been overlooked in the evaluation. Because humans are complex. Our orofacial complex is really complex. Speech production is complex. It's not just articulation.

I'm human, sometimes I rush, or miss things, or overlook them, too. So, that dynamic assessment piece and just like always returning, always digging a little deeper, they're having a really hard time with this, is there something else getting in their way from helping them get to that point? That has just been so crucial to me since I started looking at myo function and trying to go that deeper layer to really make sure that they're getting these skills.

[0:21:45] MV: I think you had Ð I see if I want to Ð I wrote quote down from Linda D'Onofrio when she was on your podcast. LetÕs see if I could find it, because I loved it, because she said something like, ÒIf you're working on a sound for six months, then it may not just be theÓ Ð

[0:21:58] MM: Yes. That has become my new motto. I'm like Ð

[0:22:01] MV: Ð perfectly, but I was like, when I was listening to the podcast a few weeks ago, I was like, ÒYes, that's so true.Ó That's kind of where I'm coming from. We need to relook at it again, because what did we miss? And anyone who works with children, they are inconsistent, unpredictable. So, when you aren't doing an assessment, they might not be at their best. They don't always open their mouth because you told them to. Maybe you're seeing them in the afternoon and they nap, so they're not happy being there. So, they're not as compliant or really willing to show you their mouth. ItÕs a phase of looking at that mouth. So, I think sometimes that happens, too. We just don't get all the information during that evaluation for several factors and that's okay. Like you said, we're constantly kind of reevaluating and diagnosing as we go in therapy as well, and that's part of what we do. We take data, we evaluate, we make adjustments in our therapy, plan based on that data.

So, it's something that we do and I don't think we really recognize it in that way. Overall, we're just like, ÒOh, we're just doing therapy.Ó But there's so much more to it on that. I do want to also mention, I use Dr. Richard Baxter's, some of his case history information, and he has that free online for people with Alabama Tongue-Tie Center. He has amazing information for just tongue ties, and sleep, and breathing for infants, children, and adults. So, that's a great website and place to go.

[0:23:33] MM: I love his tongue tie screener, because it really covers like feeding, speech, sleep, neck, shoulder pain, all the things that are related to tethered oral tissues. It's a very comprehensive screener.

[0:23:45] MV: Yes. What I also want to mention, Madi, is when we are looking at oral-facial structures, and we're looking at the client, as they're speaking, as they're eating, we want to look for any compensatory strategies. So, thatÕs a thing too. We also want to look at function, right? So, just because they have a potential, I say potential, because I can't diagnose a tongue tie. I say a potential lingual restriction, that doesn't always mean that they're going to have issues because of it. So, we have to look at what impacts function, and that is also important. And getting that training in these areas can help you figure out, is this, affecting their function? Is this a compensatory strategy? Or is this okay for just them, as who they are as a human being? 

We're all different. We all have different structures, and that's okay. So, it's very interesting when you really start to dive deep into that, because you can have an orofacial myo disorder, always the long ones, right? And an articulation disorder, like that's common. You can have an articulation disorder, though, without an OMD present. So, that's why this differential diagnosis is super important to kind of tease that out, and help figure out what's going on for that client.

If it's articulation versus phonology, versus apraxia, like we have speech sound disorders. We're constantly differentially diagnosing those, because there are different therapy strategies for each of those. So, you don't want to have a phonology kid that you're just doing a straight, traditional articulation approach for, because one's linguistically based and language-based, and one's not. So, we are doing that already a speech-language pathologist. This is no different. We're now just looking at the oral structures as part of that puzzle, and is that affecting things as well, or is it not?

[0:25:42] MM: Yes. I love that you're really like teasing that apart because you can have an OMD, and then you can maybe have articulation, a phonological, or maybe even apraxia. Or you might have just a phonological disorder with no OMD. So, you wouldn't need that function approach to treat your linguistic-based phonological disorder. You might have an artic disorder, but not have an underlying OMD. So, I think for me, and ever since I learned about myofunctional therapy, it was really seeing that it was this missing puzzle piece for a lot of kids on my caseload, but not necessarily every kid fit into this OMD category.

It's like, once again, for me, orofacial myology has just been a tool that I've been able to add into my tool bag to figure out when does a kid need this or an adult? When do they not? How does it fit into the puzzle? Personally, this myofunctional exam has kind of just taken the place of myo oral mech exam that I was doing before. It's just significantly more comprehensive one that also looks at respiration a little bit more closely, and things like that. But I find it really interesting that I don't think Amy Graham classifies herself as a myofunctional therapist, but her oral motor exam that you talked about covers airway, and respiration, and malocclusion, and palate width, and all of the things that we're looking at as a myofunctional therapist.

[0:27:11] MV: Yes. I agree, 100%. It's just anything that you can find that helps you, to differentially diagnose is super important. So, I've just found these things along the way with different trainings, and even different Instagram and Facebook posts, sometimes you'll see that and be like, ÒWell, that looks really interesting. Let me look a little further into this. Let me think, let me look to see if this is something that I could use to help me, to help my clients.Ó So, that's kind of how these things have come along. But I've just found these things along the way, and they're amazing. And people are out there doing the research. People are out there Ð professionals are out there, I guess, I should say, not just people. Professionals in our field, in the dental world, in the ENT world, in the sleep specialist world. Other SLPs are doing research, or developing things that are more helpful, whether it's a checklist, or orofacial exam, or whatever it may be, and they're providing these sometimes for free, and sometimes at low cost. I think we need to kind of find those things and not reinvent the wheel. They've already put in the time and effort to research all that for us.

[0:28:19] MM: Yes, one thing that I just want to kind of touch on, because there's definitely a lot of like myofunctional Instagram accounts out there in social media. But what I love that you said, is you see something that sparks your interest, and you don't just take it at face value and move along, but you take the time to dig into it further. So, not what this podcast is about necessarily. But I think that's really important in this age of like social media information to always like dig a little bit deeper, and verify that for yourself. Look at the references they shared them. Go ahead and Ð it's okay to dig a little bit deeper and use those Instagram or Facebook posts as like a jumping point to inspire you. But to always like dig a little bit deeper, find out a little bit more information about what that person is sharing.

[0:29:00] MV: Yes, but social media, I feel like has helped us so much to be able just to see what's out there in our field. Before social media, we were all kind of in our own little area of the country, or in the world, in our own state, in our own clinic, in our own school, and you really only had the people around you to kind of figure it out. So, I feel like it's opened the door just for a lot of great information to see kind of what's going out there. But you've got to use your problem-solving and critical thinking skills, and see, is this something that's appropriate to use with your clients? But also, is it beneficial? Is there any research to it? Using, that evidence-based practice for that type of thinking, is what we need to do.

[0:29:42] MM: For sure, yes. It's really funny. I definitely have to think Hallie Bulkin for being the reason that I fell into the myofunctional world, and it's because I saw some really interesting Instagram posts from her.

[0:29:52] MV: No, she's good at marketing it, so I think she does catch your eye. But for me, I was getting into pediatric feeding, and I was taking multiple courses from multiple providers. learning more about pediatric feeding. Hallie Bulkin was one of those, with Feed the Peds, but I kept hearing things about orofacial myofunctional disorders. I was like, ÒWhat is this that I'm just not as familiar with?Ó So, for me, this has been now about a four-year journey out of my entire career of really diving into what are orofacial myofunctional disorders? What does that mean? How can I implement that with my current clients? I'm able to see them through a different lens. And that has been very beneficial, I think, overall to help them make the best progress that they can, because if they've got large tonsils, adenoids, or potential lingual restriction, I can look at that, that I can say, ÒHey, is this contributing?Ó Maybe they have a low tongue resting posture, open mouth breathing.

This is leading to a tongue thrust, which is why they're there for speech, but I now can see why maybe they have that tongue thrust, instead of it just being, ÒNope. That's just what they have now. We'll just work on some articulation stuff.Ó So, I need to know what I'm looking at the implications of these structural issues on the impact on their speech-sound production, their development, and their intelligibility. We talked about fatigue sometimes, you'll see it there. So, in feeding aversions, we see a lot of that in feeding therapy, when I'm doing that at our clinic. A client cannot lateralize their tongue in the oral cavity, out of the oral cavity. So, they're not able to clean their molars to get the food out. They're not able to have a rotary chew, because that tongue is not moving laterally. All the things that we know should be happening, but I want to know why this is a problem, why this is an issue for this client, and start there.

So, I also learn a lot from Char Boshart, and I have read a lot of what Pam Marshalla did. But a quote I like from Char is wherever the jaw lips and tongue rest is where they work.

[0:32:06] MM: Oh, that is so good.

[0:32:08] MV: That was eye opening for me, that simple quote. So, wherever the jaw, lips, and tongue rests, so our typical oral resting posture is where they work. To me, if your tongue and your jaw, if everything is not where they should be in that typical or resting posture that we know about, then that's going to affect their ability to produce things in the correct way, because they're not even starting it in the proper positioning. So, you're going to see more compensations. You're going to see more distortions, or substitutions, maybe, because of that right there.

[BREAK]

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[EPISODE CONTINUES]

[0:33:14] MM: And just as a reminder, proper resting posture is when the tongue is lightly section to the roof of the mouth, the teeth are slightly apart, and the lips are closed, and you're breathing through the nose. If you want to hear more about that, you can go back to Ð we talked a lot about resting posture in Linda D'OnofrioÕs episode and Kristie GattoÕs episode. So, if you want to find out more about that resting posture, go check that out there.

That is also true. So, one thing that I would love for you to share is, so you've been on your myofunctional journey for the last 4 years out of, was it a 25-year career?

Has these last four years, have you had any like big eye-opening moments? Or how would you summarize that it's impacted like the care that you've been able to provide your patientÕs clients since implementing that?

[0:34:01] MM: For me, it's been a drastic addition, a good addition to what I was currently doing. But it's made really drastic changes in how I view things in what I do. Because this kind of was that missing piece that I really didn't have training on, until I started taking just a variety of different courses for orofacial myofunctional disorders and therapy. I now, just 100% look at the clients differently when they walk in the door. I'm just automatically looking at their face, looking at their tone, looking at the symmetry, looking at nasal breathing versus mouth breathing.

I'm looking at Ð sometimes these kids come in with a sippy cup or a bottle, or something, or a snack, and I'm watching them eat it while they're walking into the room. I'm looking at kids, especially those with articulation issues a lot differently. I was taking a lot of things at face value and not digging deeper for most of my career, and we would work on R, we'd work on L, we'd work on S, we'd work on that tongue thrust, we'd work on that frontal lisp. But I never really dug deeper to figure out the why, or what was that underlying reason that they were having issues saying that sound. Now, that I'm able to look a little deeper, and know what I'm looking at, some of them don't have any issues and we just need to practice, right? We need to do placement things, like where do you put your tongue? Where do you put your lips? We teach that. They're more aware. We practice it. I never do drill. And with pediatrics, we're always doing more play-based therapy or floor time, versus table time. We do a variety of things to keep it motivating. But they get it quickly once we point it out, right? And we practice it, and practice it. We generalize it, they get it.

So, it's made a difference, for those, that I can see now the difference between children who don't have an underlying issue and who do, because the pacing is different, the progress is different. They get those sounds faster when there's not an underlying issue. So, I also know that I need to dig deeper and figure out why are they having this tongue thrust, and why is their low tongue resting posture, do that tethered oral tissue screening. Do those things so I can see it, and then I can refer, if needed, if the family is on board. And it's multidisciplinary. It's not just me. I mean, I need to work with others. I need to work with OTs. I need to work with PTs. I need to work with teachers. I need to work with dentists. I need to work with sleep specialists. I need to work with ENTs, right? There's so many professionals, dieticians for feeding, nutrition, all of those.

So, it's very important that we start to also get comfortable as speech-language pathologist with those referrals, and kind of figuring out who's in our community that can help with that. So, that's one of the things that's important. If you do start doing more of that orofacial myofunctional therapy program, you may need to refer out to these specialists and to start figuring out who in your area are doing these things. Come up with that team, because if you're doing it, and you're the only one, you don't have anyone to refer to, then there is definitely going to be minimal progress if they need other things addressed. So, that's an important step also to take. It's not just you, you can't do it all.

[0:37:20] MM: That's another thing with a myofunctional, like getting into myofunctional therapy has really expanded my mind to. Whenever I was in school is like, ÒOh, I'm the speech therapist. I work on speech sounds. That's my thing.Ó But it's like, ÒOh, wait a second, we can like take a step back, because we're working with humans, and it's all interconnected.Ó And we can't just focus on our one little area. We really kind of have to take that step back and kind of look at the whole picture, and that requires the team approach.

Well, that is awesome and super enlightening, hearing just kind of your journey, and how that's changed your practice, and how you're approaching your kiddos. I know, it kind of sounds like you feel more effective. 

[0:38:01] MV: I do.

[0:38:02] MM: What I kind of got out of that.

[0:38:05] MV: I do feel like I'm able to be a better speech-language pathologist. My treatment is better, my ability to guide and help these families has improved so much, and especially if you have someone come in, if they're older, they're like, we've been in speech for 12 years, and we're in high school, and they still don't know how to do R. Then, finally we look in the mouth and we do that comprehensive, detailed exam, and we look under the tongue, and we discover that they can't even elevate, or bunch their tongue back for R, because there could be a potential posterior restriction. It's game-changing. Because if you see it, you say something to the parent, you explain, and educate like we talked about before. And if they are able to go and maybe get that release, then, there's been cases where the client comes back for like three months of therapy, and then they're done. It's crazy sometimes, what can happen.

[0:39:13] MM: Right. But I mean, that just kind of goes back to Linda, and Kristie, and Dr. McLeodÕs episodes. Speech requires muscle usage. It requires the tongue to move in different shapes, and pull back, and tense, and relax. We have to make sure that it can do all of those things and it's not impacted or restricted, or maybe they just don't know how to move it. So, they need a little help and guidance learning how to control their tongue muscle, because there's not always a tongue tie. We just can't discount that when we're working with speech sounds or feeding, what we treat a speech pathologist.

[0:39:51] MV: Exactly.

[0:39:53] MM: So, when would a myofunctional approach not be appropriate to implement? We've kind of touched on that at the beginning.

[0:40:00] MV: Yes. We kind of talked a little bit about kind of what if they're ready or not, kind of their mindset, their cognitive age, home program, their willingness to practice. So, like we said, not all speech or feeding clients have an OMD. Articulation and delays are not automatically caused by OMDs. We need to see they could have an OMD, but the function is not impacted. So, all of those things we need to Ð

[0:40:26] MM: ThatÕs a good one. Here's an OMD, theyÕre mouth breathing, they have a low tongue resting posture, but every Ð there are jaw-tongue dissociations there. There's no speech issue. They have a pretty decent chew. I've seen a couple of those. But usually there's an airway problem. So, we get the tonsils removed and then it's Ð

[0:40:43] MV: Technically, there was, the function was an issue for something that was related, maybe to speech and swallowing, right? Maybe feedings. So, it may not have been related to what's in our scope of practice, as speech-language pathologists, but it may have been impacting something else. But yes, you have to kind of be able to see that a little bit, and I feel that sometimes as speech-language pathologists, we are trained to see the client as a human being. We individualize things. We're able to kind of see the bigger picture, and I feel like we can see the whole client, and I feel like we become sometimes the case manager. We see things and we refer, or we educate, and we do that, as part of just who we are, as well as what we've been trained in, in our field of study. But I feel like we're a case manager sometimes. So, this adds to that.

So, being able to see those things like, ÒHey, they have that low tongue resting posture.Ó I looked in the back of their throat and their tonsils are 75% occluding the airway space, they're not red or inflamed. But we know that that is affecting their ability to sleep and breathe well, and it could eventually maybe affect their facial development if they're young. But also, you'll see it in older kids. It has already affected their facial development, where they have longer faces, because of that. So, being able to look at those things to determine that is super important.

If they cannot participate, maybe in the orofacial myofunctional program, I think, I mentioned earlier, it may look a little different, like pre-feeding and sensorimotor approach. So, weÕre going to work on some of those underlying things that we talked about earlier. Readiness for intervention is key. Can the family consistently practice at home? The time of year could be an issue. If it's winter, and maybe they get sick all the time, they may not be able to really work on that nasal breathing, because they're congested all the time.

So, we have to factor those things in. Do they have allergies? Do we need to send them to an allergist first, to really look at those things? Do they have buy-in? Is this a priority for the family? Because if not, then you're not going to make good progress, and you may just have to wait. Sometimes we just have to say that's okay, as long as you've done your due diligence, you've educated and provided information so that they can make the best decision for them. 

If they have a palatal expansion device in there, sometimes they won't be able to work on tongue resting posture, where the tongue tip rests. If it's one that's kind of a permanent one, not one that can be removed. So, we have to look at what is already in their mouth, is this something we can even focus on at all? There are several things like that, that would impact their ability to not work with our program.

[0:43:23] MM: Can you ever modify a myofunctional program to support speech, feeding, and swallowing skills, so like if they're not appropriate?

[0:43:34] MV: Yes. I feel like orofacial myofunctional therapy helps to prepare the oral structures for certain things. So, if a client is getting a tethered oral tissue release, so we can help prepare that tongue and oral structures prior to that release, as well as after that release. We're going to improve range of motion of the oral structures. We can improve airway, patency, and performance. We can improve overall function and coordination of the muscles to improve speech, feeding, swallowing, breathing, and sleep. So, it helps with all of those things.

Usually after that, if a client does have a tongue tie release, it's very important for that pre and post-op therapy. So, we call it neuromuscular reeducation. If the muscles have not worked in the way that they were intended, when the client gets that release, they don't automatically just start working because they weren't released. We have to retrain the muscles. That's a big part of orofacial myofunctional therapy too, or how you can incorporate that into what you're already doing with the client, if you're not doing a structured, maybe program, with orofacial myofunctional therapy.

But you can do those things with training. You have to have that training to know what you're doing and why you're doing it. So, really helping reeducate, retrain those muscles, so that they can move to the best of their ability for best function, basically is what we want to think about. So, if the muscle has been impaired and has a reduced range of motion, we can implement those oral muscular movements to reeducate the movement and establish the correct oral resting posture for speech and feeding. To me that goes back to what Char said about where everything rest, is where the starting place is. If we get that where it needs to be, then you're more likely to make more progress in your therapy sessions. 

I also like to look at Char Boshart and Pam Marshalla have tongue stabilization and mobility charts and information for consonants and vowels. They talk about jaw grading, like how your jaw has to be open for certain vowels, and for certain consonant sounds. So, that perfectly fits in with the orofacial myofunctional component when you're teaching speech sounds. What is that individual supposed to do with their mouth for that sound? How wide is their jaw open? If they're unable to do that, we need to figure out how to help them get to that point, or those sounds are never going to come in precisely, like we want them to.

But they have some great palatography. Pam Marshalla, for speech sounds where it shows where the tongue is stabilized, right? Where it braces and then where it's actually mobile, where mobility is. That is super cool to look at, and kind of think about. Because our tongue is so amazing, and how many places it moves and what it does, that if you don't want to think about it in that way, then it's hard to teach it to the client. But we are a speech pathologist, we're using parts of orofacial myofunctional therapy, in general, just based on our speech training. We do some oral motor things already. Do we use tactile cues? Yes, we're already using things that are part of this approach. We just don't know it. We're not aware of it.

So, we provide tactile cues, visuals, explanations of where the articulators are in the mouth, how to move them to produce a specific speech sound, the placement. That's a big part of what we do. Looking at placement of sounds. So, that goes in conjunction with myofunctional therapy. All of this works together really, really nicely. Most of us are already doing some of these things, even if we don't have this training.

So, getting a little training helps you just see it in a better way, or maybe implement these things in even more detail. Lots of CEUs out there, lots of training out there to add this to your skill set, and then it allows you to look at these oral structures and a different more detailed way, to make that connection between muscles and movement, and function, and how that impacts intelligibility, certain sounds that we say, and feeding skills, of course. And figuring out what are we trying to improve and why. What are we trying to do for this client? What is impacting their ability to progress or to perform appropriately? If we ask that, then we're able to set great goals for our clients.

[0:48:07] MM: Oh, I love that. It also ties in really nicely with the quote from Linda that you share where like, if we're not getting a speech sound in six months, we really need to evaluate. I think that goes for, if we're not seeing decent progress in that six monthsÕ time, not waiting, like, ÒOkay, well, I've been working on L for six months, and they still just can't lift their tongue up to the spot, to get a good L, it's always a W.Ó Well, if we noticed that, at the three-month point, that they're still not lifting their tongue, let's do a little bit more digging, let's dive in there. Because if we are giving those tactile support, and those visual cues, and all those things that we're already doing as speech pathologists, well, let's pivot our plan a little bit. That's okay to do that. 

[0:48:49] MV: Right. I see so many kids, and unfortunately, they're saying, ÒOh, they just plateaued. This is as far as we can go with them. They just can't do anymore.Ó My first thought is, ÒDid anyone look in the mouth?Ó I feel like we could help so many more, just people, individuals, if we just look in the mouth and what's going on with those oral structures.

[0:49:16] MM: I always think back to this one kid at a clinic that I worked at a few years ago, and this kiddo was working on L, and no one Ð for like, two years, and we made zero progress on his L sound. One day, he was an OT and his OT was like, ÒOh, my goodness. This kiddo, his mom brought him a cheeseburger to eat, and he took off both the buns, and then would tear the patty off, put it at the front of his mouth, and like mouse nibble at it to eat his burger.Ó And they're like, ÒWhy does he eat like that?Ó And I was like, ÒHuh?Ó I hadn't taken my myofunctional course or anything like that. But I had started doing some digging and realized how important looking at how the tongue moves.

I didn't see him all that often, but I happened to have him on my schedule that day. So, we put some peanut butter on the alveolar ridge. I tried to get this kiddo to like move that tongue tip up and realize that he had a heart-shaped tongue tip, and he could not lift the tongue off the floor of his mouth. Then, he ended up also having this feeding disorder that was completely overlooked. He was having to significantly compensate how he was eating his cheeseburger, probably because he didn't have the range to move that meat around his mouth. But this kiddo had been in therapy for several years, and it had not been caught, and that happens.

[0:50:37] MV: I feel like, unfortunately, for me, that probably happened most of my career where I didn't catch things, because I just didn't know. I didn't know either how to look, or what it meant when I saw it, that was part of it too. You may see the heart-shaped tongue or see that they cannot elevate or protrude it. But you're like, I don't know why that is or what to do about it. I think a lot of SLPs are in that position. So, getting this training, I think is super important. Learning more about orofacial myofunctional disorders and all that goes with it like you're sharing on your podcast, I think that's super important.

But I want to let others know that certification in orofacial myology is not mandatory. Sorry. ItÕs not mandatory, but training is. Training is this area is. Taking those courses is, because it is in our scope of practice. ItÕs in ASHA. ASHA has great information on the website, about orofacial myology, and they have wonderful strategies, as well as information that any of us can go look at, and learn more about. But that certification, though, is not the thing. ItÕs the training, the understanding of what you're looking at, and the why.

[0:51:50] MM: I love that. And one of the things that we talked about in Linda's course is that I know that 28-hour myofunctional training has a nice price tag on it, and it is such a commitment. But you don't have to go take that 28-hour comprehensive training. It was a great diving point. I'm very thankful that I have that knowledge. It really was a comprehensive overview of what myofunctional therapy was, and it gave you ideas for treatment. But that's not the only way to get there.

Char Boshart has the myofunctional evaluation that walks you through step by step with an evaluation form in the back about how to do a comprehensive myofunctional exam. Pam MarshallaÕs book, itÕs such a good one. Pam Marshalla has her whole text and tons of resources out there about how to use these oral motor approaches to support speech skills. I know that myofunctional therapy has a lot to do with oral motor, and we've talked a lot about improving range of motion, and mobility, and maybe working on getting tongue tip to spot for an L, a T, or a D, or an N. Starts off with just moving the tongue tip to the spot without the extra coordination of voicing. I know that sounds like an oral motor exercise.

But if you want to know more about that, Char Boshart has her five-part podcast on SpeechTherapyPD about The Perfect Oral Motor Storm that really walks you through, what were oral motor exercises? Where did we get this SMEÕs don't work perspective? And why actually, it's so important to look at the musculature of the mechanism that we're working with.

[0:53:23] MV: Well, yes, it is muscles. And if there's a weakness or incoordination, or a tethering, or anything going on, we need to look at that. It is a muscle. Muscles are important. The movement is important. And I think being aware of what you're looking at, figuring out what needs to be addressed, working on that coordination placement, right? We do placement therapy in speech. So, that's part of it to me. Then, you go into that sound as soon as you can. 

It's not that we disregard. It's not in place of speech. It's in coordination with. It's in conjunction with. It's using more that's in your toolbox, your skill set, to help this client maximize their potential. And sometimes, if you don't address the coordination and the muscle strength and the movements, then you'll never get that speech sound. If just took a session or two sometimes to do that muscle part, sometimes it doesn't take long. It goes right into the speech down and look, now they're making that progress. And if you never did that, now you've got that client who's just sitting there every week coming, which I feel personally is unethical. If I am providing services, and they're not making progress, and I'm not willing to figure out the why, or work on other things to help them because I'm just not sure of what to do, or why I'm doing it, that to me is unethical. I've got to figure this out for the client. I can't expect them to pay for my services when they're not making progress. That's just wrong.

[0:54:58] MM: Not only that, but it whenever I've had Ð before, that was one of the reasons that inspired me to look for myofunctional therapy, because I would make zero progress with a patient on articulation. And the parents be like, ÒThey worked so hard today. They're such a hard worker. We didn't get it. But we're getting close every single week.Ó I didn't enjoy walking into those sessions and it wasn't because I didnÕt enjoy the kiddo or their family, it was because I was like, ÒI'm not making a meaningful difference in this kiddoÕs life.Ó And if I felt that way going in, how did that kiddo feel coming into my session, knowing that he was never getting that sound quite right after weeks and weeks and weeks.

So, not only does it feel unethical, but it also Ð how does that kiddo feel like? I feel like myofunctional therapy sets kids up for success, especially if they can't find that placement. And I love that you hit on that. Whenever we're talking about speech, we have to look at manner, voicing, and placement. And placement is a motor move. It's a motor movement of the tongue and we have to make sure they get that motor placement. So, I love that. ItÕs a little nugget of wisdom that you shared with, right there.

Oh, my gosh. Okay. So, could you share just a little bit about what one of your treatment sessions might look like with a Ð and I know this is going to be individualized. Maybe you just want to pick like a general idea for like an articulation or a feeding kiddo. But one that you're not implementing a myofunctional program with, but using these myofunctional ideas in framework on how you would kind of approach that in a session.

[0:56:31] MV: Yes. I'm working with a six-year-old. He did have tethered oral tissue and they did get a release, and he is looking into they're looking into Ð theyÕre looking at his tonsils, adenoids because they're large. So, we did the pre and post-op with him, with moving his tongue in his mouth. What I incorporate is opening the mouth as wide as you can, that jaw opening, and then trying to elevate that tongue as high in the mouth as you can, to kind of stretch that lingual frenulum. And you can't stretch it. I mean, like after, increasing the range of motion, is what I mean to say.

We also incorporate that tongue elevation, but also lingual palatal sectioning. So, being able to pull your tongue all the way up into the roof of your mouth, and then we click it. So, most kids can do a click, but then to hold it is another story. If you can do a click, I'm like, ÒOkay, that's the first step.Ó But then I'm like, ÒOkay, pull your tongue up to the ceiling, or to the sky, or pull it up as high as you canÓ, and that is increasing that range of motion and coordination. But that is also helping with some of the sounds like R, being able to move that tongue in different ways like that, and having that lingual palatal section.

I'll incorporate those within our articulation therapy sessions. We talk about placement a lot. So, where the tongue needs to go to produce L. On the alveolar ridge, of course, I don't use that term in sessions, but behind your teeth, and you feel the bumpy part. I use the mouth puppet a lot to show them and move that tongue around. I use Dum-Dums suckers and things like that to help them know where to put their tongue, and to increase that awareness, because that's what it is too. Most adults don't know what their tongue does when they're talking.

So, I can't expect the child to know when I'm talking about without providing more tactile and visual cueing. That's what I incorporate to get that placement, or to get that strength, or that coordination, and then we practice that with the speech sounds. Then, once they've got it, then we can move through either the traditional hierarchy for articulation approach, where you're like, isolation, syllables, words, all that. Figuring that out for them first, though, is super important. But we have sessions where we are maybe doing those movements, and then we're practicing that L sound right away, in an activity that's fun and motivating for the child. So, that's just an example of kind of how I would incorporate it in a session.

[0:59:00] MM: Awesome. I love that. That's really similar to how I do that with kind of that younger age range as well. Honestly, even if it is, like six, seven, five-year-old that I'm doing, well, I mean, any age really, that I'm working through, and they have sleep sound airs, I know that, in my traditional training, you work through, you establish the foundation, and then you move into speech. But if my patientÕs parents primary concern when they come in, is they are so unintelligible. I'm like, ÒOkay, we're going to do these myofunctional exercises. And then for the last few minutes of the session, we're going to take these myofunctional, this systematic myofunctional exercises that we worked on, and then we're going to pair them back to their speech sounds that we're working on.Ó

I think, going back to what you mentioned earlier, the client values and what they hope to get out of therapy, they can't come and be like, ÒOh, we're concerned about speech sounds.Ó I'm like, well, you have a myofunctional disorder. So, we're going to do this instead of that. It's really like, which sometimes that needs to happen first. But that's a conversation you have with the parents, and I met Melissa at a Waltz Fritz course.

So, the biggest takeaway I got from that was shared decision-making with your client, and it's like always just like having those conversations being like, this is what I see. How do you think we should approach this? What are you thinking? Let's talk this through together and come up with the plan that you think would be best for your child together. But yes, oh, man, Melissa.

[1:00:24] MV: When I work with kids, though. It's all about being creative, too, and helping them. So, when I'm working on nasal breathing, of course, making sure they can breathe through their nose, and with lip closure and nasal breathing, weÕll do smelling activities. So, we use smelly markers and smelly playdough, and we'll have a little paper bag with like a lemon in it, and we guess what's inside by smelling. Then, I'm enforcing and reinforcing lips closed, breathe through your nose, smell what's in there. We try to get three smells in a row and then we get to guess what it is. Or we're coloring a picture with those smelly markers.

We're trying to be really creative in how we are getting to it because their kids. Just sitting there and saying, ÒClose your lips, breathe through your nose. We're going to do it 10 times.Ó How boring is that? We try to structure it and pair it with things that are motivating and interesting and fun, but are relevant. Smelling through your nose is important, but that's helping with correct or a resting posture.

[1:01:25] MM: I love that idea. I am going to have to do that. And also, what a great idea for those picky eaters that are working on smells and things like that too. Oh, that is a great idea, Melissa. How fun.

[1:01:36] MV: To me, it seems simple, doesnÕt it? But it is. It's very powerful and they are willing to close their lips and smell through their nose for a certain amount of time, based on where you are, of course, in their abilities. But they can do that.

[1:01:49] MM: Yes. Like how functional is that also? So, that is awesome. Well, Melissa, we have done our hour. This was so amazing. You are a wealth of knowledge, and I learned so much from you. You gave me some really good little nuggets of wisdom today. I'm going to try out these smelly, out of some bags because that is genius. But thank you so much for coming on and really sharing like how myofunctional therapy can be used as a tool for differential diagnosis. This is going to add so much value to the overall series. I know people are going to really enjoy hearing about this.

[1:02:25] MV: Thank you for having me, Madi. I enjoyed it. This was fun. I love talking about it. So, thank you.

[1:02:31] MM: Oh, absolutely. It's my favorite topic. So, as a reminder, for everyone joining us, make sure that you go onto your Course Content page and complete all of the modules for a credit for this course and we will see you next time.

[OUTRO]

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SLPL S11E9		Transcript

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