SEASON 11 EPISODE 1

[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 speechtherapyppd.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. 

[EPISODE]

[0:01:04] MM: Hello. Welcome to the first episode of the speechtherapypd.com mini-series, Making Sense of Myo. My name is Madi Metcalf and I am a speech-language pathologist that works in a clinic, focusing on the assessment and treatment of orofacial myofunctional disorders in pediatric feeding and swallowing. I'll be your speechtherapypd.com host for this podcast, Making Sense of Myo.

Before we get started, we have a few items to alert you to. This episode is 60 minutes and will be offered for 0.1 ASHA CEUs. I am the host of this podcast and I receive an honorarium from speechtherapypd.com and I do not have any relevant non-financial relationships. Our guest, Linda D'Onofrio, receives compensation for this presentation from SpeechTherapyPD and she doesn't have any relevant non-financial disclosures.

Now, without further ado, we welcome our presenter, Linda DÕOnofrio. Linda has brought several courses to the speechtherapypd.com, including her 15-hour treating orofacial myofunctional disorders course and her six-hour course, oral myofunctional therapy change instructors, plus several others where she dives into the ins and outs of myofunctional therapy. 

Linda D'Onofrio has completed her degree in communication disorders at the University of Oregon, her medical externship at the Oregon Health Sciences University Medical Center, and her clinical fellowship at the Oregon VA Medical Center. As an adjunct instructor, she has taught undergraduate courses in oral myofunctional disorders and craniofacial disorders. She has reviewed manuscripts for the Journal of Clinical Pediatric Dentistry, Folia Phoniatrica et Logopaedica, and the Journal of Oral Rehabilitation.

Her paper, ÔOral dysfunction as a cause of malocclusionÕ in the journal Orthodontics & Craniofacial Research was awarded the most downloaded article for the journal in 2019 and 2020. She has lectured on oral physiology at several universities, including Stanford and Tufts. Currently, she is an adjunct instructor at the UniversitŠt Uam?

[0:02:58] LD: Jaume

[0:03:00] MM: Jaume in Catalan, Spain Dental Masters Program, and the Vienna School for Interdisciplinary Dentistry. Welcome, Linda.

[0:03:08] LD: Thank you so much for having me. I didn't realize what a mouthful that was phonetically. I'll change my bio and just make it shorter next.

[0:03:18] MM: It was great. I'm so sorry. I definitely should have remembered to ask about those pronunciations. Well, letÕs dive into this, Linda. Our first question today is, what is orofacial myology?

[0:03:33] IAL: Okay, orofacial myology, like any other ology, is the study of a topic. Strictly speaking, orofacial myology is the study of the muscles of the face. It's not really a term I use professionally. When people ask me what I do, I'm a speech-language pathologist. My specialty is in the diagnosis and treatment of orofacial myofunctional disorders.

[0:04:04] MM: That is so great, because I definitely feel like, as a newer clinician learning about myofunctional therapy, I didn't quite realize that distinction, so that is really great. What is myofunctional therapy?

[0:04:22] LD: Okay, well, let me back up and define the disorder, because the therapy is what treats it. I had a unique opportunity in my career to redefine myofunctional disorders in a paper that I got to publish a couple of years back in the Orthodontics and Craniofacial Research journal. An orofacial myofunctional disorder includes any dysfunction of the lips, the jaw, the tongue, and/or the oral pharynx that interferes with the normal growth and development, and function of other oral structures.

This is often a consequence of a sequence of events, either in utero, or after birth, or a lack of intervention at critical periods. The result is malocclusion and suboptimal facial development, okay? That's what an orofacial myofunctional disorder is. It's a structural functional behavioral disorder. If we're going to define the treatment for that, and I actually got to do this definition at a presentation at ASHA in 2019, and before that at the International Association of Orofacial Myology in 2018. OMT, oral myofunctional therapy. These are therapeutic, exercised-based techniques. I want to really define that specifically because some people think they are just exercises and that therapy is not a part of the process.

Let me say it again, OMT are therapeutic, exercise-based techniques that are based on the principles of motor learning and neuroplasticity, things that are well-established in other fields of research. This is meant to stabilize, tone, strengthen, or just improve the range of motion of the skeletal muscles of the face and neck. They're used to treat a wide range of orofacial myofunctional disorders, okay? That definition can be found in my research and in my presentations and in other places that I'm happy to share that later, too.

[0:06:39] MM: Can you go over some of the changes, or things that might not happen in early development that could lead to some of these orofacial myofunctional disorders (OMDs)?

[0:06:47] LD: Okay. In my paper, I discussed 10 areas of oral dysfunction. Some of them can start in utero. Many of them start after an infant is born. But certainly, children can be born with cranial facial disorders, which we know we take classes as a speech therapist. But we can also be born with orofacial dysmorphia. Our jaws might not be aligned at birth. We might be experiencing retrognathia. We might be experiencing a high angled mandible at birth, because of many epigenetic experiences. We might be experiencing a high narrow palate at birth. We might be through prematurity, or small gestational age, or other impacts. Again, I discuss these in detail in my paper, including maternal obstructive sleep apnea, that there can be changes that can be seen, but are not screened for in this country at birth, but there are many things that can happen after a child is born. Nasal obstruction in preschool is probably the most common thing that we see. The mouth hangs open in order to breathe. That has consequences over time.

[0:08:11] MM: I think that's so interesting because so many SLPs work in early intervention. They work with that birth to age three population. I think it's so important to really take that step further and look at how is our cranial facial complex functioning because it is going to have long-term impacts on how we grow and develop. Yeah, I love that we're touching on that.

[0:08:36] LD: One of my first school practicum experiences was an entire kindergarten classroom, where no one could breathe through their nose. I was the only one extremely worried about that. I spend a lot of clinical time teaching nose-blowing. 

[0:08:51] MM: Do you ever make referrals whenever you see that?

[0:08:55] LD: My reports, I make public and I share in my study group. My first referral for, I would say, 90% of my patients are to ear, nose, and throat with the course my report going before the referral. My second referral with my report going ahead is to an orthodontist. My third recommendation is my therapy.

[0:09:19] MM: Ah, so you're really trying to take care of what are these structural things that are standing in the way of me making my progress on my speech and language and swallowing goals?

[0:09:30] LD: If the child walked in with a cleft palate, wouldn't you do the same?

[0:09:34] MM: Absolutely.

[0:09:36] LD: The child walked in with Crouzon syndrome, wouldn't you do the same?

[0:09:39] MM: Yes, ma'am.

[0:09:40] LD: If the tongue cannot reach the hard palate for any reason, wouldn't you do the same?
[0:09:46] MM: I sure do. We've gone over what is an OMD, what are some of those early signs, and we've touched a little bit on Ð oh, yes.

[0:09:58] LD: Early signs can be a little Ð let's expand on that because parents see things and they show up at a speech therapistÕs door with questions. I joke, all my kids walk in with a speech disorder and they all walk out with a sleep disorder. Parents walk in with concerns and the biggest one is, ÒIs this normal? My child is not sleeping. Is this normal? My child is not communicating at what I think is normal. My child is not eating. Is this normal? My child is not.Ó

Often, our job as a speech pathologist is to do that initial screening in and out of our areas of specialty and make those appropriate referrals. People come in, mostly about sleep and feeding, okay, and communication. I got to tell you, your communication is a secondary experience. Sleep and feeding are the foundational abilities to do that. I haven't eaten breakfast yet and I'm only on my second cup of coffee, okay? But there's messy eating and parents want to know, ÒIs that normal? My child never shuts their mouth when they eat.Ó Again, normal. ÒMy kids had enlarged tonsils for a long time. My pediatrician isn't concerned. Is this normal?Ó

We are the ones that are often the first person to say, ÒYou know what? Let's look at that more deeply. Let's do a screener for articulation and see if a more in-depth evaluation is required.Ó Let's look at the facial structure and function and see if a more in-depth evaluation is required. Even if a speech therapist doesn't specialize in OMDs, they should be able to see the signs and symptoms, and so should every kindergarten teacher in my mind.

[0:11:52] MM: Yes. Do you have any recommendations for screeners that you could use for identifying pediatric sleep disorders, or things like that, so that SLPs can know, have a tool in their tool bag to know how to screen for these things, know how to ask parents about them?

[0:12:08] LD: I just returned from the Vienna School for Interdisciplinary Dentistry. I did three lectures back-to-back on teaching the screeners for airway dysfunction. I did not know that I would need to have those ready today, but I have.

[0:12:24] MM: IÕm so sorry.

[0:12:26] LD: No, no, it's okay. I have all those links available. I've discovered that the IJOM, the International Journal of Orofacial Myology, actually has collected those. The Ferris-6 is the most current, www.ferrist-6.org/tools. You can find that protocol. They're all publicly available. The OMES, which I'm going to not remember, because I didn't know I was going to be just dated this this morning, is still used in research. That protocol is 40-years-old. There's lots of great ones. There's lots of great screening protocols for orthodontists, for speech therapists, for kindergarten teachers.

[0:13:13] MM: Just because this might be new information for SLPs like, ÒOh, wait. I should be asking about sleep.Ó Can you just briefly bring that relationship to how OMD might be impacting sleep? What SLPs are already looking for when we do an oral mech exam? How could that point them into the idea that this could be impacting sleep?

[0:13:36] LD: Let's walk through all three. Because the one thing we want to make sure is that speech therapists understand how speech is connected to OMD.

[0:13:43] MM: Absolutely.

[0:13:44] LD: How dysphagia is connected to OMDs and sleep, because they're all three the same, okay? How we breathe and swallow cannot be separated from each other, especially when we're unconscious, okay? Because our breathing sets up our swallow, our swallow sets up our breathing, and this is how snoring and other behaviors begin. When we talk about the research because one of the papers I'm going to discuss in that segment of our podcast is on the direct connection. I actually got to be a reviewer on that paper, so it was very exciting. It's one of several that are connecting the signs and symptoms. Because what this paper found and what we should know is all the symptoms of orofacial myofunctional disorder are the clinical markers for obstructive sleep apnea in children and adults.

It's connected to sleep because this is where we sleep. This is where we breathe. This is where we swallow. This is where we communicate, okay? Dysfunction in this area, be it structural or muscular function, or behavioral, can have an impact on the whole system. We've talked about this because this is the nexus of structure, function, and behavior is what OMD and OMT is all about.
For speech, let's talk about, people want to know about the research on articulation. It's all American SLPs care about. Thank goodness for the other 25 professions that work in the orofacial complex, because the research on myofunctional therapy has not been led by American speech therapists in any way. It's been led by physical therapists and dentists and hygienists and sleep surgeons and orthodontic research.

In 20, let me grab this paper really quickly because it's a fantastic one that Ð it's nice that it's available in PubMed as well. The Camacho paper from 2015, ÔMyofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis.Õ This is something that at the university level and when people want to say, ÒOh, where's the level one and two studies?Ó What this really found is that myofunctional therapy, the research that has been done, and they looked at nine high-level studies in both adult and child sleep apnea patients found that this therapy was really beneficial to the extent that 50% of adults and 62% of children showed improvement in sleep.

Now if you have a child or a family member who does not sleep well, the research is also connected to daytime behavioral disorders that we now understand how sleep is related to ADHD and other things and we can't go into that detail today. Articulation is just a symptom of a bigger disorder that's actually catastrophic to our daytime functioning. The exciting paper that has just come out in, I think, April of this year in the Journal of Clinical Pediatric Dentistry, a paper that I got to review as a reviewer, which is a really prestigious request, is one out of Vietnam that showed that, again, validating that the signs and symptoms of OMD and the signs and symptoms of pediatric sleep disorders are the same signs and symptoms. This paper, ÔOrofacial dysfunction screening examinations in children with sleep-disordered breathing symptomsÕ, found that they were looking at the same symptoms over and over again.

I had the privilege of presenting at ASHA in 2017 on the differential diagnosis of pediatric oral-stage dysphagia against pediatric OMDs. The overlap between the two in etiology, in symptoms, and how they're treated was undeniable. You and I think might have talked about this at the very end of when we first met. I see oral myofunctional therapy being critical in every component of speech therapy because I see it being critical in every component of swallowing, eating, breathing, and sleeping. Of course, communicating.

We might use the muscles in different speeds and different pressures. They're the same muscles. If they are too weak to chew a carrot, they might not coarticulate in a very coordinated and efficient way.

[0:18:57] MM: Since there is going to be the video component online, is that the ASHA poster that you sent me that you're talking about?

[0:19:03] LD: Oh, yes, ma'am.

[0:19:04] MM: Do you want me to? I have it pulled up on my computer. We can talk about it really quick, if you would like.

[0:19:09] LD: I'd love to. I love the poster.

[0:19:11] MM: That is fabulous. I loved it. I shared it with my co-workers. It's like, look how crazy this is with all this overlap. We all nerded out over it together.

[0:19:20] LD: After ASHA, I shared that poster along with the second one I did on the who, what, where, when, how, and why of OMD. They've actually been used in conferences for speech therapists around the world, because I just shared it, that PDF with everyone. People have shared it over and over again. It makes me incredibly happy. Yeah, so this presentation, again, this was part of ASHA 2017. These are the symptoms of OMD at the top, okay? Rest posture issues, breathing dysfunction, tongue thrust swallow, which is a term that people know, and it's very ancient, kind of thing.

Tongue tie, oral habits, general dysfunction, hypotonia, which I used to think you could have isolated hypotonia, you can't. Enlarged soft tissue, sleep disorder breathing, obstructive sleep apnea, mal-exclusion, bruxing, and forward head posture, which, of course, impacts your upper cervical vertebrae. I have a whole one-hour lecture called the back of your mouth is the top of your spine. But these are all the intersections to the areas of speech therapy that we all work on daily, okay?

I have doctors, when I was practicing on the daily, I have doctors asking me, ÒDo you know anyone who can treat temporal mandibular pain? Do you know anyone who can do pre and post-lingual frenectomy care? Do you know anyone who specializes in pediatric sleep issues?Ó For years, it was a heartbreak. I had to say, no, no, a speech therapist will tell you that these things aren't valid and connected.

When I presented this, just so you, if you scan down to the bottom of this poster and indulge me, the folks that are on the visual left were the professors from all around the world that are colleagues and people that I admire greatly who teach this at an incredibly high level, including a doctorate program in Brazil. The books at the bottom are textbooks in Spanish and Portuguese, unfortunately. Now, there has been one English language textbook and it's very expensive. There's not a lot of access to it. On the right were the current syllabuses of courses that were available when I did this poster. Deep in the middle of it was one American speech therapist who was teaching in Iowa, which made me very, very, very, very happy. I love this poster and please share it.

[0:21:54] MM: Yes, absolutely.

[MESSAGE]

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[INTERVIEW CONTINUED]

[0:22:24] MM: It's okay. We can also maybe upload this to the resources on the SpeechTherapyPD website, because I thought this was just really interesting just tying all the aspects of OMD, how it's directly impacting the areas of what SLPs are treating.

[0:22:39] LD: Okay. I want to say one more thing to young clinicians and anyone who's never presented at an international forum like ASHA. This poster got accepted. I had to write all the background research for it, but this was the simplest thing. It was so much fun to present. I just stood there and smiled and because it had colors and stuff and pictures and it didn't have a lot of text. Don't be intimidated by submitting a poster, because a little can go a long way. I just want to say that to people who've never done it.

Okay. The evidence, one of the things I got to do and I want to cover if we have the time and you can indulge because I do believe Ð oh, we do because we're ahead on evidence. I want to share a little bit of my presentation that I did at IOAM and at ASHA on the evidence base in our field. Because I did, I wanted people to see what existed. Now, I do need to write this up. It is on me to publish this and I am making space for that in the next 12 months to take care of this.

This was a meta-analysis. When you come to a conference, only 300 people in a room get to see this. It's not like, there's a big spread of information after you present, even at a very prestigious place like ASHA. I have a lecture and again, I can give you the link to it that I presented that was on all the research that's available. What I'd like to do if I can, can I share the screen for a moment?

[0:24:19] MM: Yeah.

[0:24:20] LD: Is that an easy thing for us to do? I know you weren't necessarily prepared to do this today. Okay. I can share my screen.

[0:24:29] MM: Perfect.

[0:24:30] LD: Okay. I'm not going to go through this lecture, because this actually is a long one. But I just want people to know when they hear that oral motor doesn't work, or [inaudible 0:24:39] don't work, there was a meta-analysis on something, you must look very carefully at how that was conducted. Because if they only look at six studies that prove that it doesn't work, then what did they really look at and how do they analyze it?

For the purposes, because people want to know what is in the research on oral motor in general and in speech specifically. I presented on this, and just so you know, I always reveal my bias when I present, because I don't even pretend, just so you know. This is again, the definition of OMD. This is where the first time I really got to define what treatment was. I wanted you to see the method of my meta-analysis before validating it or dismissing it, because I went through everything I could publicly get my hands on because that's what I thought my audience could get a hold of. I tried to use every conceivable word that might be used internationally.

Only looking for something that says, oral motor and articulation will limit what you find in the international research. Because the French don't call it that, and neither do the Germans. I looked under all the terms that are used for myofunctional therapy, including functional physiology, myofascial rehabilitation, which is what it's called in France. I found hundreds of articles, and I tried to limit what I found to the study. I eliminated a lot of them after I found them because I didn't want it. I didn't care about prevalence. We can talk about that another day. A lot of people assume, assume that oral motor impact speech. They dismiss it in the first introductory paragraph of their paper, in this country where we don't even believe it's real. I had to dismiss all those papers, too.

I had to dismiss breathing stuff because our field doesn't recognize it currently outside of respiration for things like dysarthria. I threw out every rat and monkey study that I found. But I found hundreds of journals who present who, excuse me, publish on this topic. Hundreds of them. I found them in lots of different fields. It's just not ours. I showed who's publishing and what. I discussed levels of evidence because I broke the papers down into levels of evidence. You only want to look at level-one papers. You wanted to dismiss all the fun stuff with cerebral palsy, kids with cerebral palsy at the bottom? Go ahead. Those are in there too, because the level five studies are those case studies that are super interesting that match what your caseload looks in real life, right? I also separated it by the areas that speech therapists are interested in. Go ahead, please.

[0:27:43] MM: Oh, sorry. Just because some people might just be listening to this, I just want to highlight that you found 35 level-one case, or level-one research papers on this. That is 35 after excluding some. I'm sure there was more level one that was around this topic anyways. Just to Ð

[0:28:04] LD: Sort of. Level one papers really do have to meet a certain level, but they might have been about something, another topic that wasn't about efficacy. Because I wanted to show, does OMT work? Yes, there were 23 level two studies, 29 level three, 50 level four, and 74 level five, because if you were as a clinician ever going to do a study, what would you probably contribute to this database?

[0:28:35] MM: Probably a level five.

[0:28:36] LD: Four and five. Yeah. Now, if you're in a university, what do you have access to? I want to tell you, it's heartbreaking that in 40 years, American universities haven't bothered to contribute to all of the papers that I found here. It's not entirely true, but it's true. The 10 areas of application that I discuss at length in this presentation, which again, is available, okay, because I got to share it and nobody's going to read it. The areas are articulation, dysphagia, elderly and special populations, I'm doing it in alphabetical order, non-nutritive sucking and chewing, which is all orthodontists ever cared about, occlusion and orthodontic retention, which was my working specialty, oral function and chewing, basically feeding disorders, post-surgical stability, which became a subspecialty of mine later. I ended up working for head and neck surgeons before I stopped seeing patients directly. Of course, obstructive sleep apnea, temporal mandibular disorders, and then tongue and lip ties.

These were the 10 areas I discussed in this meta-analysis. For those who can see, you can see how many papers I attached to each one of them. What's really sad is granular research is very, very new. We're going to give tongue and lip ties a pass. I did the last 25 years, but there's 40 years of oral motor research to access. I wanted to keep this meta-analysis completely relevant, so I only went back 25. Nine papers on articulation.

Well, let's look at them really quickly, and then we'll fly, okay? Because you wanted to see the evidence base for speech real quick. I found level three, four and five papers, found three of each. Not a robust space. By the way, I joke all the time that I'm a speech therapist who never does speech. To me, these are just symptoms of a disordered skull.

To me, this is not something that I'm actually actively looking for anyway. I summarized the research, okay. I show what level it was, what they did, how many people were in this study, and what they found, what was a relevant sentence to encapsulate, or relevant phrase to encapsulate the research, so that if you were interested, you knew a little bit about it, and you could look more, okay? I regret that I didn't make this a searchable PDF. Maybe when I publish it, I will. That'll be fun. That'll be fun.

Okay. But I went through and I showed that you know what? They've actually found some significant improvements in speech. Oh, shocker that if you work on the muscles, the muscles work, okay? But the real problem is everything from ASHA contradicts what some of this research says. It says, there's no evidence base, so there is no evidence base, okay? We could produce more and this is how. For those who can only hear, I actually wrote suggestions, including creating more level four and five studies. Level three is a retrospective study. We're capable of it, especially if we work on it as a team, okay? Maybe in a clinic, you can do a good retrospective study.

Higher-level surveys, heck, that's what the whole insomnia thing started from with some low-level survey, a survey. We can change the world, apparently, with a survey. Swallowing is actually a more critical function than speech, so let's look at that. Breathing, by the way, is a more critical function than swallowing, because if you can't do the breathing, you can't swallow. These are how many papers in 2018 and 2019 I found to discuss this topic on efficacy. Eight level-one papers on dysphagia for OMT. I think feeding clinics should be using that research. Seven level two. Nine level three, 15 level four, 16 level five on feeding and swallowing and myofunctional therapy, okay? Because these are foundational structures, if you chew well, your master development is very different than if you don't chew well. Your jaw structure builds on muscle tension, bone density builds in response to muscle needs.

I mean, the physical therapy research and neuroplasticity research have come together. We should be really operating off the fact that we do have skeletal muscles in the face. They respond to exercise. Just, this is why we go to gyms, frankly. Then I highlight the research here, okay? Let me know if we're running on time, or if we need to wrap up, because you know how I get Ð

[0:33:26] MM: Yeah, I think we're doing great.

[0:33:28] LD: Okay, so the first couple of slides here is me just talking about the level-one studies in our field, okay? These aren't necessarily done by people who are then producing things that other speech therapists are reading. They're finding, dysphagia research is evolving to a more exercise-based practice than just modifying diets, okay? Because if you make the face stronger, you make the tongue pressure better, you can make the swallow more predictable, okay? That's how you keep from getting pneumonia. The overlap is unmistakable.

The research on this and I have a summary page for swallowing, shows that exercise-based therapy shows tons of positive outcomes in oral stage and oropharyngeal swallowing, because there's skeletal muscles in your oral pharynx too, shock of shocks. Higher-level studies had mixed results because they didn't Ð they weren't able to pull apart the exercises and maybe they didn't clearly define them. Everybody wants to know which specific exercise solves which specific problem. Imagine walking into the gym and saying, ÒMy hip hurts. Can you give me one exercise?Ó They would be like, ÒWhat are you talking about?Ó

Field clinicians, again, we can do better. It's called practice-based evidence. We can make it, okay? We can contribute. That's where evidence-based practice comes from. Us. Certainly not coming up from universities. They're just teaching what we do, okay? We need to be working in a multidisciplinary fashion because it validates all of us when we're working together and looking at each other's fields. When we work with an orthodontist, or a lactation consultant, or a surgeon, our work is validated, because we are working and being watched and it's a collective group, okay? This is fantastic. Hospitals and universities, it could be pumping this stuff out, no problem. Yes, please, please.

[0:35:29] MM: I just have two things that I want to ask about, and some of them are some that we touched on briefly before we got started. You mentioned a lot about exercise. Does that mean that SLPs need to be doing this physical therapy for the mouth? Is that what this exercise-based for myofunctional therapy, is that the direction it's going in?

[0:35:55] LD: It could, and I hope it doesn't, frankly, because I think that's swinging a pendulum way too far to the other side. I actually have made jokes that speech therapists don't think exercises matter at all, and dentists think they're the only things that do. It's like, please, y'all, please, it's called therapy in the middle, okay?

Your zygomatic holds your mid-face, which holds your lower face, okay? It's a thing. The stronger my zygomatic are, the different my jowls will look as I age, okay? Just you know, I turn old really soon. I turn 59 next month. It makes a difference in facial tone because the muscles don't have a lot of fat in between the muscle and the skin on the face, where it does in other parts of the body. But no. But if you ignore the muscles of the face, and just tell a child to try again, you end up with a kid who's working on S for years. I say this in all my courses. If you're working on a sound for more than six months, perhaps it's not a sound. I mean, it's just consider that it's not a sound.

I have a whole six-hour course on Vimeo, which is part of a five-part Vimeo series, not to plug my own stuff off your website, but still. I have six hours of showing how precisely if your lips don't fit together, shocker, some sounds are hard to make. If your jaws don't fit together, reaching your tongue out of your mandible to your alveolar process might be a little bit bigger reach than for other folks. I mean, if your palate is high and narrow, instead of wide and flat, again, you might have a hard time with a handful of sounds. Put an object in your mouth, and you will change the gross structures all around it. Because functional matrix theory shows just like in hydrocephalus, bones will move to accommodate higher functions, like brain swelling. Well, your face will completely move where it is to accommodate higher functions, like breathing.

[0:38:15] MM: I love that we just had this full circle moment right there because at the beginning, we really talked about sending out referrals to ENT, ortho, rolling out those structural things. Rolling out those structural things are so important for our kiddos with speech-sound disorders. Everything you just said was Ð

[0:38:31] LD: ItÕs critical.

[0:38:32] MM: - like, okay, let's look at the alignment of the jaws. Let's look at the width of the palate. Are they going to be able to put their tongue where it needs to go to produce these sounds?
[0:38:41] LD: Before we ask them. I say this in all my courses. For those who know me, this is a repeat. I cannot count on my fingers and toes how many school speech therapists have called me the day after a child, well, a week after a child got a palate expander installed. SH, CH and J magically came in in one day, sounds that they've been working on for years, because the molars finally lined up, sha ja. You can't say chew until you can physically chew. That comes from molar contact, cha, cha, cha, cha, cha. They expand the palate, fix the crossbite, the kid gets the sound. What were you doing before then? Telling them to try again. It's in their head.

Before a speech therapist becomes a physical therapist for the face, okay, because I am not one of those either, you might want to see Ð look at the structure, look at the muscle function, and then extrapolate the behavior from that.

[0:39:51] MM: That makes so much sense, too, because nothing works in isolation. We're a human being. You have to look a little bit outside of just your standardized articulation assessment and really look at, is the structure appropriate for doing all of these speech sounds?

[0:40:11] LD: There is a very famous person who said in the middle of an ASHA conference in front of all the ASHA faculty that they never looked inside the mouth when they gave an articulation test. I couldn't help myself, but I had to stand up and say, that might be the problem. Because if you're not looking, la, la, la, la, la, la, what did you miss?

[0:40:34] MM: It sounded great, but Ð

[0:40:36] LD: No, it didn't. There's a lot wrong with that. I can make a T in my glottis. I had a stutter, a person who stutters to teach me how to make a glottal T. You can make sounds all over the place. I can make an S out of three different sides of my mouth. It's critical that we watch placement, that we watch production, that we watch speed and coordination, patty cake, patty cake, patty cake, bad doggy, bad doggy, bad doggy. I like it a lot. Later, Peter.

[0:41:14] MM: Yes. For those that are just listening, whenever Linda said, ÒLa, la, la, la, la,Ó Ð

[0:41:19] LD: Yeah, because that sounded strange, right?

[0:41:22] MM: Yeah. She was just modeling that you can make these sounds and they can maybe sound acoustically close to your production. But her placement was all wrong. As we've talked about this whole episode, the way that our soft issues are functioning is going to direct the growth of our hard structures. We want to help set our patients up for success as they move through life, beyond just saying their sounds in an intelligible way. When we're doing those articulation tests, we just really want to encourage SLPs to watch what they're doing, not just rely on your ears, but really pay attention. Are they using the tongue tip to go up to the alveolar ridge for those TD and then L sounds?

Do they have that draw stability that they need to move through and coarticulate? When Linda was just demonstrating that, so watch the webinar, or the video portion on SpeechTherapyPD, so you can get that.

[0:42:20] LD: Yeah. One of the things that I talk to people about, because we can compensate with our jaw. When our tongue does not have full range of motion, our jaw can compensate. I can say, ÒDa, la, la, la, laÓ using my jaw, or I can open and say, ÒLa, la, la, la, laÓ with independent differentiated full range of motion. What I tell people is you can play piano with web fingers. Lots of folks do it. You might even be good, but you'll be working harder than people who have normal range of motion. Everyone deserves normal range of motion in their hands, in their hips, in their legs, and in their face. The jaw does not have normal range of motion, if the lips do not have normal range of motion, if the tongue does not have normal range of motion, we can compensate. We're human beings and we're intelligent, okay. It's just a sound. I can make an S through a hole between my two teeth and it'll work until the orthodontist closes my diastema and then the lisp will start. It's just a matter of time. That's why it's often a sequence of events that reveals a myofunctional disorder.

For speech therapists, what I want you to do is always be asking why? Why is this kid in speech? Why does he have an articulation disorder? Why can't he close his mouth? Why do I see a tongue thrust swallow? Before telling a child to close their mouth and breathe through their nose, why aren't they doing it already? Could closing their mouth cut off their only air supply? Why change the behavior if it's not a behavioral problem? Consider changing the structure if it's a structural problem.

[0:44:12] MM: I think that's so interesting, too. I love the saying, we should be breathing through our mouth as much as we eat through our nose. If they are not breathing through their nose, they're not doing it, because they just don't want to. They're not making that decision consciously. There is a reason why. Doctors see their patients for 10, 15 minutes, maybe for lucky 30, they're in and out occasionally, all these other providers, a dentist is going to see them for the 10 minutes that they're in chairs, the hygienists for the 20 that they're doing the cleaning. As a speech pathologist, we see our patients every week for an extended period of time, we get to do them so intimately. Sometimes we're the first line of defense that's going to catch these things because we get to see them. We get to build these relationships.

We get to see, oh, well, maybe they're breathing through their nose today, because they're Ð or they're their mouth, because they're a little stuffy. It is allergy. Like, my allergies are a little hazy right now. Then three weeks later, they're still doing it and mine are cleared up and the weather's a little bit better. We can see these relationships a little bit more clearly sometimes than other providers because we do get the ability to have these ongoing relationships.

I just think it's really awesome that we as a speech pathologist, not only can we better their lives by making them more functional in their speech and feeding, and language skills, but we can make them more functional human beings by making sure that they have the appropriate structure to thrive. That's personally why I got into myofunctional therapy because I wanted to not Ð I wanted to make them better people. I didn't want them to compensate. They're six. Why are they compensating at six?

[0:45:52] LD: Yes, yes, yes. Use the word when that's what you're doing.

[0:45:56] MM: Yeah, I love that.

[0:45:56] LD: If youÕre teaching [inaudible 0:45:56], or if you're compensating, say so.

[0:46:01] MM: They don't have the appropriate structure. Right now, we're teaching a compensation to temporarily improve this until X, Y, and Z can fall into place. I love that.

[0:46:11] LD: I'm so happy right now.
[0:46:12] MM: I know. I am, too, because I Ð

[0:46:14] LD: Okay, so you were asking about Ð this moves really nicely into the next piece of this. Because you're describing what you already can see and know. I just got an email last night from somebody saying, ÒIf I watch your courses, can I then see a patient?Ó ItÕs like, okay, one, we're speech therapists, we're already seeing the patient. The patient's already there. You're just now realizing with new eyes, though, why? Okay. Oh, they can't make an S, but they also can't make any of the other alvellers, na, ta, da, la, without doing some weird thing with their jaw.

They used to make fun of things, like jaw slides. Then you realize that the child only eats on one side. There's a $7,000 orthodontic case that has yet to be diagnosed on the other side and people make fun of it. Like, ÒOh, my jaw slides.Ó ItÕs like, yeah, if you saw that in a 40-year-old, that's a surgical case. Stop making fun of it. Maybe teach bilateral chewing, so that the muscles pull the jaw. It's not about learning a handful of exercises, although those are great. It's not about learning what tools you need to stick in the mouth, although those are great. It's not about what program is needed for temporal-mandibular pain, although those are great.

It's about looking at your patient with a dynamic assessment model, wondering why they are presenting the way they are today, what you need to do to get them out, graduate them, not dismiss them. What can you do? And who is your team to help you? Make your referrals at the beginning of the process. Find mentors for things you don't know. Take courses where you have gaps in your knowledge. Because I meet people who work at very high ends in hospital situations that don't realize how much they know. They just don't know what it's called or what they're doing, so they may need a particular class. Then there's very young clinicians who simply just got out of school and are like, ÒWhere do I find a tools course?Ó It's like, well, they're over there. Go take one.

I know lots of people, because they come to my courses because they've taken a lot of strategy courses, but they don't know how to put the process together. I'm more of a process person, okay. I am a top-down process, so we need to understand why we're doing what we're doing. Where does this evidence come from and where do we take it? Speech therapists really, if your education was not robust in cranial facial structure and disorders, build up your cranial facial base. I tell people, man, go take a dental course. We did not learn a dental occlusion the way we really need to sometimes go sit in on another class in another department, okay?

Take a sleep dentistry course, because they exist in dental schools. If you are in a school situation, you never really took a lot of feeding courses, because another profession does that in your work environment, you need to understand how that sucks alive a swallow that you're watching impacts all the alveolar and palatal and feeler sounds. Again, if you tell a child to do something, but you're doing it because you learned it, but you don't understand the why behind it, you can cause other problems. I work with a lot of kids with behavior problems. I don't put things in people's mouths. Most of the time, I'm a very naturalistic therapist. That's why when you ask about exercises, I demurred.

I also work with people that are very rule-based. If you explain it in a very concrete way, they'll do it the exact same way every time. If you teach it wrong, you have to unteach it and that's its own thing. The education you need depends on that. I tell people, if you find a course that you find interesting, get the syllabus and research the instructor. Who is this person? What have they done? What is their skew? What is their view? Are they a physical therapist who works with temporomandibular pain? Again, go outside your field. Are they a speech therapist who specializes in lingual frenectomy? Go do that. Just, there's a lot of commercial courses and people are making money right now off this, because it's very, very hot, because sleep disorders are epidemic in our culture.

[0:51:00] MM: Does an SLP that they're like, ÒMan, this sounds like my caseload. This is making a lot of sense to me.Ó Does a speech pathologist need to go out and spend a large amount of money to do myofunctional therapy? Or is it more like you were saying like, I can go and I can build my knowledge base?

[0:51:21] LD: I need a prototype. Give any general, but I need something to start from here. A school speech therapist?

[0:51:29] MM: Ooh, I guess that's a really good point because they're such a broad basis.

[0:51:34] LD: What if you're in a preschool? What if you're in a nursing home? What if you're in a NICU? Because I have a lot of IBCLCRNs and a lot of SLPs who are IBCLCs, who are very, very interested in this because they're working at the very beginnings of life with children who may not be thriving. Who knows truly?

If you worked in an outpatient rehab with folks who were coming out of hospital, but they were only literally there for 30 days, what you're doing is making assessments and recommendations and shooting them on. You may never actually perform treatment that way, okay? If you're in a school, you may be bound by an IEP and you may only be able to see things and make general recommendations and you may be scared off in your district about doing that. Whole different podcast. What are you doing there? What's your education need to be like there? It really is. It's truly vast.

What people should know is that their understanding of how oral motor impacts articulation, language, cranial facial development, academics, and sleep needs to be reconsidered. Just research advances. New data comes out. Other fields contribute to our base. Read. I'm happy to share. I make my bibliographies public to all my lectures, so that if you ever want to read my presentation or come see a course of mine, here's all my research. Just read the biblio. It's my favorite part, most articles anyway. See what's happening. See where it's coming from. See how much of it's being produced. That's really what I want people to know is that the last 25 years, the amount of research is huge. I happen to be out of graduate school 23 years. If I wasn't keeping up on other people's research, how would I know this?

[0:53:47] MM: I think that, whenever I first got out of grad school, I would have never imagined that I needed to look at all of these other fields of study to build my knowledge as a speech pathologist. I really love just how much we've hit on today. I'm like that interdisciplinary nature and not being afraid to step outside of just SLP research to build our knowledge base, because all that helps our clinical judgment and our clinical skillset, which is a part of evidence-based practice. I really love that we're really bringing awareness to that today.

[0:54:25] LD: I wish that I had more invitations to speak from speech therapy, speech pathology departments. But I have literally traveled the world lecturing to dentists, your nose and throat doctors, oral maxillofacial surgeons, orthodontists, pediatric dentists, the heads of departments for these dental schools. They will be referring, because I've been lecturing to them, so I hope speech therapy is getting ready. I'm available if anybody needs me. What I'm telling you is the world is about to change in our field for the better. A lot of frustrations that clinicians have had, like how come this has not worked for a kid? This might be ringing bells for them.

There's lots of associations and there's more every day. As speech-language pathologists, all we need are our seeds to diagnose and treat structural, communicative, and feeding and swallowing disorders, how they manifest. If we don't have the graduate education or the postgraduate training, then perhaps we should not take that patient and we should refer to a colleague who does. I don't specialize in augmentative communication disorders, but I've got a girlfriend down the street. She's awesome, okay?

I can screen for that. I can see that a child might have a need and I might include it in my assessment and then make an appropriate referral, just like I would for anything else, okay? We don't have to specialize in it if we don't want to. If we love dyslexia and we love these other things, but we see this, we can start asking why, we can start screening, and again, we'll share the screening protocols, and we can start building our team, okay? Because my team includes speech therapists who specialize in other things.

[0:56:25] MM: What I'm finding, the more that I get into my own clinical practice, is I can't do it on my own. It's not just a speech pathologist that's going to make the difference. It really is that knowledge of being able to say, ÒI need to build this team.Ó This child needs an OT, a PT. They need to go to the orthodontist. They need an additional SLP for this area that I'm not as skilled in, and that's okay to refer out if it's not your area.

[0:56:55] LD: You want to make friends, refer out, okay? You want to show youÕre confident at your own clinical skills, refer out in the areas that aren't your clinical skills.

[0:57:04] MM: Absolutely. Yes, that is so awesome.

[0:57:09] LD: The team sometimes already exists. The fifth part of my five-part series on Vimeo is about coordination of care. Again, six hours on coordination of care. You mentioned earlier, but I want to re-emphasize, that speech-language pathologists are not only sometimes the first provider to see these things, and we are not only the provider who may be seeing them on the weekly, seeing change over time or the lack of it, but we are also, in many cases, the most highly qualified provider to diagnose the disorder, to treat the disorder end to end at any point in a patient's life. Do we need ENT? You bet. Do we need orthodontics? Uh-huh. Do we need pediatric dentistry? Do we need occupational therapy? Do we need sleep medicine, sleep neurology? Of course, we do.

These patients come with their pediatricians and their this and their that. The team sometimes exists. It's our responsibility to communicate with an effective report, not to the mom, but to the team, because we're providers, and to build the team that exists, make the team better, inform the team of our successes, because if our patient does not improve, the team will go, ÒYeah, we knew it wasn't real.Ó If our patient improves, they'll say, ÒEh, it wasn't them,Ó unless we report.

I love a good report. I love a good discharge summary. I write those things for free because they are a joy to write. They're also only about 15 minutes of report writing. It is a team effort, and we are a huge expert contributor to the team. We are the ones that show oral dysfunction. We're telling the ENT what we see and what we'd like to see. We're telling the orthodontist the concerns that this structure is having on breathing, swallowing, chewing, rest postures, and speech. We talked to the orthodontist about what we'd like to see. Yes, the child is very young, but we are seeing changes to eating habits, because of this structure. Can't tell other people what to do, but we can say what we see. We can do our due diligence.

If anybody looks in an old report, they'll go, ÒThat speech pathologist saw the ankyloglossia, saw the crossbite, saw the recessed jaw.Ó They did their job. That's what I want is I want SLPs doing a better job. Always be getting more education. There's never enough. There's always more to learn in anatomy and in physiology.

[0:59:53] MM: Absolutely.

[0:59:54] LD: In and out of our field. I recommend to folks all the time, get a mentor, make a friend, join a study group.

[1:00:04] MM: I know a really great study group on Facebook, the oral myofunctional study group. It's fabulous. I've learned so much from it.

[1:00:12] LD: Oh, thank you. Professionals only. Tell a friend.

[1:00:15] MM: Yes. It's great. By this really fabulous SLP, Linda DÕOnofrio.

[1:00:20] LD: This has been really fun today. Thank you so much for having me.

[1:00:22] MM: This has been so fabulous. I'm so happy that we did this. I think that this was a great way to kick off this myo-functional mini-series for SpeechTherapyPD. We really covered what is oral myofunction? What is myofunctional therapy? Why do we need it? I love that we really brought more awareness to the fact that what speech pathologists are treating does have an anatomical and physiological basis. We cannot ignore that.

I'm really happy to spread awareness. I hope that all the SLPs that listen to this are able to take some really good information, get their brain juices flowing and maybe inspire them to do a little bit more research on their own. This was so fabulous, Linda. I appreciate your time so much. You had so much goodness and words of wisdom to share and we really appreciate it.

[1:01:14] LD: Lots of fun today. Thank you for having me.

[1:01:16] MM: Absolutely. We will see you next time on the Making Sense of Myo Podcast. Thank you.

[1:01:23] LD: Bye.

[1:01:24] MM: Bye, Linda. It was great chatting with you.

[OUTRO]

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SLPL S11E1		Transcript

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