SEASON 11 EPISODE 4

[INTRODUCTION]

[0:00:14] ANNOUNCER: Welcome to SLP Learning Series, a podcast series presented by SpeechTherapyPD.com. The SLP Learning Series explores various topics of speech-language pathology. Each season dives deeper into a topic with a different host and guests, who are leaders in the field. Some topics include stuttering, AAC, sports concussion, teletherapy, ethics and more. Each episode has an accompanying audio course on SpeechTherapyPD.com and is available for 0.1 ASHA CEUs. Now, come along with us as we look closer into the many topics of speech-language pathology.

[DISCLOSURES]

[0:01:04] MM: Hello. Welcome to another episode of Making Sense of Myo. My name is Maddie Metcalf, and I'll be your host this evening for another episode of Making Sense of Myo. Before we get started, we're actually going to take a quick poll in the comments or the chat section. So if you want to hop on there and answer a quick poll, that would be awesome. So we'll leave that up for about a minute and then we'll get started with the episode for tonight. 

This episode is 60 minutes and will be offered for 0.1 ASHA CEUs. Tonight, we're going to have Dr. Angela McLeod on the podcast to talk about how orofacial myofunctional disorders can impact speech sound production. Dr. McLeod has a Ð she gets an honorarium for speaking on the podcast this evening, and she does not have any relevant non-financial disclosures. For myself, my financial disclosures are that I get an honorarium for hosting this podcast and I don't have any non-relevant financial disclosures. There are not any handouts tonight for the podcast.

Then, I'll go ahead and learn a little bit about Dr. Angela McLeod. Angela McLeod, Ph.D., CCC-SLP, is a clinical associate professor and speech-language pathologist at the University of South Carolina. Her clinical background includes work with clients across the lifespan in healthcare and educational settings, as well as home health care in early intervention. She has earned certification at the qualified orofacial myologist, QOM. However, additional clinical and research interest include speech sound disorders, literacy, language development, and disorders in cultural and linguistic variation.

Dr. McLeod is returning to SpeechTherapyPD.com. She's been featured on the First Bite podcast two times, where she discusses myofunctional therapy and had the two-hour course about orofacial myofunctional disorders. 

[INTERVIEW]

[0:02:56] MM: Welcome Dr. McLeod. I'm so happy to have you on the podcast tonight.

[0:03:00] AM: Hello, Maddie. Thank you for having me, and I'm delighted to be here.

[0:03:04] MM: So last week, we learned all about the physiology of swallowing, and how OMDs can impact our swallowing functions. This week, we're really excited to learn about how that can impact speech. So, can you start off by outlining key components contributing to speech sound production?

[0:03:23] AM: Okay. Sure. Well, first of all, I'll say that speech production is quite complex. We could literally speak an entire hour solely on what all is involved with making speech sounds successfully. But for the sake of time, I'll give a rather brief overview, and I do have some talking points, just to ensure that I don't get Ð I'm super passionate about this topic, and I don't want to get so carried away that I forget to share the important details, so I do have some talking points.

First of all, we know that we initiate speech by sound starting, or the source of sound starting in our lungs, and then it travels through our anatomy from our lungs into our larynx. The larynx, of course, is where vocal folds are. When air vibrates across the vocal folds, then we have what's called phonation, and that's actual sound. However, we can produce some sounds without phonation. We'll talk about that in just a few minutes. Ultimately, the air continues upward into our pharynx and then into our oral cavity. Sometimes air can pass through our nasal cavity as well, giving rise to Ð we classify as nasal. But assuming that the air bypasses the nasal cavity, and then goes into the oral cavity, we have various sounds that can be produced with the structures that we call articulators.

Again, excluding the nasals, let's say that we focus only on the tongue, and the jaw, the lips, the teeth, the soft palate, the hard palate, and the alveolar ridge, we get various types of sounds. We actually classify those sounds according to the place of articulation or the place of air constriction along the vocal tract. The manner of articulation or the manner of air constriction, basically, more or less constriction, perhaps one sound relative to another. Then, of course, there's voice saying, meaning whether the vocal folds are vibrating. Again, that's a very simplified version of speech sound production. It's important to note, however, that multiple processes must be intact and functioning in order for us to have a fully functional speech sound. So at the cerebral level, everything must be working, respiration needs to be intact, phonation needs to be intact. Proper resonance, meaning our ability to contrast oral and nasal sounds. And of course, as I've mentioned, articulation, what we actually do with the air inside our mouth that can maybe contrast one sound from another. That's a very simplified version of it. 

[0:06:16] MM: So interesting that there's so much Ð we think of it as, "Oh, it's just speech. It's just articulation." But actually, there are so many things that have to fall into place for that just articulation to work the way it's meant to.

[0:06:28] AM: That, when we consider that, we wonder how anyone speaks typically at all or speaks [inaudible 0:06:34] because so many things could potentially not happen the way they're supposed to.

[0:06:40] MM: Absolutely. So can you explain what some of the features or symptoms of an orofacial myofunctional disorder, OMD that can impact articulation?

[0:06:49] AM: Sure. Anytime I talk about myofunctional disorders or orofacial myofunctional disorders, I do a lot of teaching and some working students who are just learning these concepts. I like to encourage them to first of all, sort of break the word myofunctional down. That's a very basic definition. But Myo means muscle, and functional means how something works. So essentially Ð and disorder, of course, is when something's not doing the job that it's intended to do. So putting all this together, you could very broadly define a myofunctional disorder as a problem with musculature, and particularly oral, various aspects of oral musculature. Such that, perhaps our feeding, or our resting posture, or in this case, our speech just isn't possible in terms of typical speech or normal speech. 

I will also, in answering this question, refer to the definition of orofacial myofunctional disorder that was given to us by Dr. Marvin Hanson, who is an SLP, and has often been contributed, or his definition, he's been attributed with giving us the most definition of what an OMD is. According to his definition, it refers to abnormal resting, labial, and lingual posture of the orofacial musculature, atypical chewing, and swallowing patterns, dental malocclusions, blocked nasal airways, and speech problems. Consider all those, and how they work together to allow us to produce both healthy speech, and healthy feeding and swallowing.

So if you think about, when you ask the first question about what mechanics are involved in speech production, I mentioned the tongue. So let's talk about just the tongue, like none of the other structures. One of the activities that I've asked students to complete in my many years of teaching, articulation disorders is to stabilize the jaw, so they can open their mouth and hold the jaw standing. And with effort, use only subtle adjustments of the tongue, and see what happens. And adjusting the tongue only without any other articulators gives rise to very different vowels and diphthongs. 

Again, the tongue itself is a major articulator, such that we can make it Ð make the difference between an ah, and then uh, and then eh, and then oh without really moving the other articulator. So if the tongue is a major articulator, and that is one of the parts of the anatomy that is grossly affected by an OMD, you can understand how speech sounds could also be affected. I think about Ñ if a person has an inappropriate resting posture, they're not holding the tongue in their mouth appropriately, even when they're not speaking. Over time, that could affect the alignment of the teeth. That could give rise to mouth [inaudible 0:10:03]. 

Similarly, if they're exhibiting tongue thrust, that could give rise [inaudible 0:10:08] and think about the number of sounds that we Ð that are dependent on actually having proper spacing of the teeth, proper buildup of air in the anterior part of the oral cavity, such that air is released. For example, the fricatives and the affricates. They are released with the appropriate amount of pressure from the mouth if there are gaps and spaces in between the teeth that would prohibit inappropriate air escape. Then, I think about, again, going back to the tongue, an inappropriate forward resting posture might lead to distortions of certain sounds like the S and the Z. That would require our tongues to be in a very precise placement in order for them to be perceived as the standard productions. 

Again, those are just a couple of things. One that comes to mind that I've personally had experience with that may not be so readily thought about is maybe the R, and the vocalic R. Because, for those phonemes, our tongue has to have a certain amount of tension, and certain muscle contractions must take place. If the person's OMD is affecting their ability to achieve those muscle movements, those muscle contractions, they could inadvertently have difficulties with any sound that requires certain tension. Those are just a few examples.

[0:11:41] MM: We have somebody ask if you could repeat Marvin Hanson's definition of myofunctional disorders.

[0:11:46] AM: Okay. I absolutely will. It says that it refers to an abnormal resting labial and lingual posture, or labial or lingual posture of the orofacial musculature, atypical chewing, and swallowing patterns, dental malocclusions, blocked nasal airways, and speech problems.

[0:12:13] MM: I love that you touched on dentition. Whenever I had just started being an SLP, I didn't realize what a story dentition could tell us about how the tongue was resting, how are they swallowing. I think that's such an important part to look at, after I've kind of learned more about myofunctional therapy, especially when we're working with those speech sound disorders. We have a really narrow palate. It might be harder to make those sh-sh, and zh sounds, and things like that.

[0:12:38] AM: Absolutely. Yeah, it's all related. As I mentioned earlier, everything needs to sort of do the job that's intended, and the structure needs to be intact, the function needs to be intact in order for us to produce sounds that are accurate or perceived as accurate.

[0:12:57] MM: Whenever you're working with a child or an adult that has an orofacial myofunctional disorder, what speech sounds do you typically expect to see distorted with that individual?

[0:13:08] AM: Okay. Classically, some of the ones that we might anticipate are the S, and of course, S blends, the Z, but perhaps some of the alveolar sounds. Like for example, I've sort of explained how potentially the S, and the Z, and S blends could be distorted if the tongue is not resting properly, or if they're malocclusions, or some combination of the two. Those features could affect those phonemes.

Sometimes a person may have perhaps a tongue tie that might restrict optimal placements for some of the other. Even S for example, that could be impacted by inappropriate ability to achieve the very precise location of the alveolar ridge for the S to be produced, for air to flow across a very narrow stream, or through a very narrow string to be produced as accurate. We also could observe problems, as I said, with the L, the T, the D, and the N. I mentioned R and already explained that. 

I think the takeaway is that, have knowledge that any or all of those phonemes could be affected. In your assessment process, you need to be thorough, and look at the various aspects of the anatomy that could be contributing to why a person isn't achieving those ideal placements.

[0:14:43] MM: I love that you touched on how important it is for the ideal placement. But sometimes, it's okay for them to find that compensation, and maybe produce a lingual alveolar on the bottom with their tongue to finger down using their mid-blade. But we do want to kind of strive for optimal if they have that capability to do that. That's something that's been mentioned in previous podcasts, just whenever we give an articulation test, we have to watch the mouth and see how are they producing that sound, not just hearing the acoustic property of it.

[0:15:14] AM: I was going to just sort of add to what you were saying, an example that I can recall from clinical practice. I worked with a young adult who he knew something was wrong with his speech for Ð from the time that he was old enough to pay attention to his speech. Sometimes younger kids aren't really concerned. But when he became old enough to be concerned, he realized that something was wrong, but he never pursued it, or figured out. I needed to see someone about this.

But by the time he reached adulthood, the career that he chose, actually required a lot of public speaking. So he sought out some therapy to basically improve his competence on the job. As a result of coming to the assessment, it was identified that he did have some distortions. Further investigation revealed that he actually had a tongue tie, and that one thing led to another. He then began to talk about how he would compensate. So when you're talking about compensating and creating alternate placements for various sounds, he talked about how he learned different ways of making certain sounds to sort of get around the difficulties that he knew were there, but didn't know how to explain or didn't know how to correct. This, again, was an adult. He had done that for a large amount of his life.

Then, as a result of that, when we finally realized that he needed to see someone for having the frenula revision, and he continued therapy for post-surgery exercises, and also speech, he had to sort of retrain himself to speak with more standard placements because of the compensatory movements that he acquired over time.

[0:17:10] MM: Did he have improvement in intelligibility? Like that he noticed doing the therapy, and the release, and using correct placements versus the way that he was compensating?

[0:17:22] AM: Okay. I'm not sure if I understand.

[0:17:26] MM: After doing the myofunctional therapy and changing his placement, was he able to perceive those improvements in his intelligibility himself?

[0:17:34] AM: Oh, absolutely, yes. He told us, and I say us, because at the time I saw him, I was working with a graduate student in training. But he told us that as a part of his history, his close friends were comfortable enough letting him know that they sometimes had trouble understanding him. They thought that he could take it in a positive way coming from them as really wanting to help him. He knew that something was wrong. But again, he was in that comfortable group of friends, it was okay for him to relax. But he did report after the procedure and after therapy, that he didn't have to have a guard up, or sort of monitor his speech. He could just speak naturally because he learned to speak more standardly, and without those compensations.

[0:18:23] MM: That's really awesome. Michelle has a question about this case study. Was he intelligible after the tongue tie was released, or did he need therapy after this point to really improve with intelligibility?

[0:18:34] AM: He still needed therapy. There was some of the therapy that was needed to address the change in the anatomy to prevent tissue reattach. But then, the other part of the therapy was for him to, again, continue learning placements. We basically started some of the speech therapy and did as much as we could, realizing that there were things that needed to be medically addressed. He went and got the procedure, and then continued his therapy, and ultimately was discharged. Interestingly, while we're talking about him, he also talked about how he had noticed that there were certain areas of his mouth that he could not clean with his tongue when eating before the surgery. But he could easily remove all the residue after the surgery. 

[0:19:21] MM: Awesome. What a true reason, like why we do tongue tie releases, to improve function for oral cleaning, for articulation. That's fabulous. We have a couple of questions. We have four questions that are pretty relevant to what we're talking about. They're all from Kate M. She has some great ones. She asks, so are errors resulting from an OMD considered compensatory or obligatory? To my understanding, obligatory errors are caused by structure directly and compensatory, maybe nonstandard production. You had to learn to deal with structural differences.

[0:19:55] AM: She actually sort of answered her own question. Generally, if they have no other ability to make the sounds, they just have to do the best that they can with their structures, if that makes sense. If they're aware of differences, they may modify what they would naturally do to get something that's more standard. I would consider that compensatory, but it is obligatory if you can't make your tongue go higher than it naturally will if it's restricted if that makes sense.

[0:20:26] MM: Then, Kate have three other questions. Are speech sound disorders secondary to OMDs considered a motor speech delay?

[0:20:35] AM: I don't know that motor speech is the right term. Because when I Ð honestly, when I think about motor speech, I think about dysarthria and apraxia. In my formal training, we would just say that their speech sound errors that are influenced by OMDs, but I don't know if I would consider them motor speech.

[0:20:52] MM: Could a child with an OMD also have a motor delay, though?

[0:20:56] AM: Oh, absolutely. Yes. 

[0:20:58] MM: Would that change your treatment approach if you suspected an OMD along with a motor speech disorder?

[0:21:03] AM: Honestly, it's kind of hard to say because every case is approached individually. It just depends on what's going on with Ð like what the symptoms and the features are that you find in your assessment process. But I would say, it's not impossible that you would have more than one approach, addressing certain errors based on what this clinical profile reveals, and other features or needs according to other clinical data.

[0:21:36] MM: Our next one, do the atypical patterns resulting from an OMD cause or contribute to muscle weakness, cognitive speech errors? Or does it more so affect placement and therefore considered more articulation?

[0:21:48] AM: Well, anytime you weren't on myofunctional therapy, it's considered motor. By nature of definition of a myofunctional disorder, it is motor. But the key is that you've identified something in your assessment process that needs to be addressed. Not that you're just randomly stabbing, or hypothesizing that there's an underlying motor issue, you actually have a distinct assessment protocol, where you have measurements, and you've made certain observations, and you've sort of gone through. I think we're going to talk about this some tonight. But there are certain protocols that you follow, that would give you the insight regarding the nature of the disorder, to know that this is indeed myofunctional, and this is the type of intervention that would address those features.

[0:22:42] MM: Then this last one is, not necessarily related to articulation, but I think it's still a great question to address around myofunctional disorders. With OMDs, there is often chronic open-mouth resting posture. In your experience, once the airway issue is resolved, and it's more of a habit change, is this more difficult to change purely because it requires behavioral change or their significant contribution of muscle strength, stabilization, and proprioception issues?

[0:23:08] AM: Well, I think about Ð any clients that we serve who Ð the case is that the underlying organic etiology of the problem has been addressed, there is still typically a behavioral component that needs to be addressed. Sometimes it's kind of hard to tell what's what. But like, for example, with cleft palate, they have undergone the surgeries, and you've gotten medical clearance that they have the ability to contrast oral, and nasal sounds. But just because the anatomy, the anatomical component has been addressed, there isn't an automatic acquisition of the ability to reliably and consistently contrast oral from nasal sounds. That's why they're enrolled in therapy to learn behaviorally, how to alter those tendencies. It's no different here.

It's very possible that you refer for airway competence, identify whatever, or the practitioner you refer to identifies what the cause of the airway problem was. They addressed that, but it doesn't mean that automatically, the person's going to start breathing through their nose versus their mouth. Also, you might consider the longevity of the tendency. If it's a more chronic problem, it may take more time for them to acclimate to the new behaviors, and if it's something that's in the short term.

[0:24:51] MM: I know a lot in my treatment, I do a lot of reminders. We talk a lot about it, we discuss it a whole lot. We have little visuals that we use. Getting the parents, if their child [inaudible 0:25:04] pediatrics, so getting the parent on board. If they're an adult, I'm like, "Okay, where is somewhere Ð let's put sticky notes on your computer, sticky notes on your steering wheel, little reminders." I tried to support them a lot in creating that habit change, but it is a habit. It's not just, open the airway, release the tongue if it's needed. Okay. Here you go. It's a lot of work to create a new habit.

[0:25:27] AM: I mean, a lot of the things that we do in myofunctional therapy, R&D, teaching new habits. So it's a gradual process.

[0:25:37] MM: For sure. Because the swallow pattern, if they're Ð how they're changing their placement of articulation? All of that Ñ Kate says, thank you so much for answering all of her questions.

[0:25:48] AM: Oh, you're welcome.

[0:25:50] MM: Okay. How can Ð back to speech sound disorders. How can a myofunctional approach be used to improve articulation skills when myofunctional disorders found to be the cause?

[0:26:06] AM: Okay. Well, again, I think it sort of goes back to what you identify in your assessment. In a detailed assessment, I actually pulled a little checklist here so that I could Ð remember, I told you, I don't want to veer too far from the topic. This is my handy-dandy, go-to, to ensure that I cover some of the important things. In a typical myofunctional assessment, like one of the things that was mentioned was mouth breathing versus nose breathing. So we're going to look at that. We're going to look at the tendency toward open mouth, and mouth posture. We're going to assess them, swallowing, so we can observe for potential tongue thrust. We're going to assess their frenulum. So we're going to look for and possibly even measure the tongue, and the lip frenulum. We're going to assess whether they have certain habits. So are they nail-biters? Are they thumb suckers or suckers of other fingers? Do they chew on their clothing? Do they bite straws? Are they pacifier users? We're going to look at all those habits and tendencies.

Obviously, we're going to assess their speech sounds. We're going to assess their, not directly, assess their airway competence, but we could actually screen to determine if a referral to an ENT or a sleep specialist is needed depending on the age of the individual. We're going to look at tongue resting posture, we will look at the dentition, and whether malocclusions are present. Whether there's tongue scalloping, venous pooling Ñ

[0:27:56] MM: Can you explain what that is?

[0:27:58] AM: The venous pooling? It's when Ð it kind of looks like they're dark circles under the eyes. They're sometimes called allergic shiners. When you say that, that's evidence of, perhaps a referral needed to an ENT or an allergist to assess, perhaps that's why they're mouth breathing. There's something that's medical that's underlying that.

[BREAK]

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[INTERVIEW CONTINUES]

[0:28:52] AM: But the point is, we're going to have such detailed data. We even look at like strength, whether they have lip competence. But we're going to have such detailed data from our assessment that we could then perhaps try to determine if some of what we're seeing that's not typical with those features, so it'd be indeed related to the speech sounds. What we'll do then is, perhaps develop a tailored treatment plan that's designed to address those features that we've identified as problematic. Inadvertently, some of those could influence speech sounds.

I have a couple of examples here. Let me look through my notes here. I just got so much here, because I didn't want to, again, omit important information. But like, say for example, if we identified that they are not properly Ð hence, say, the tongue. Let's say, we want them to be able to demonstrate that they can make a skinny tongue, versus a flat tongue, and to sort of alternate between the two when they need to. Because we understand that being able to tense the tongue and pull it back is important for successful R. That might be an exercise that we implement.

Or another one might be if, let's say they had problems with mouth breathing, they were chronic mouth breathers. So they tended not to ever really get good by labial closure, that might influence some of the bilabial phonemes. So you might have exercises where they have to squeeze their lips around. I'll think of one that we do with kids. They squeeze their lips around a Dum-Dum lollipop, and you tug. Their job is to squeeze tightly enough to sort of resist you pulling the lollipop out. Does that make sense?

[0:31:08] MM: Yes, it does.

[0:31:09] AM: Or maybe, again, related to the lips, they could potentially Ð because of not having that habitual tendency to keep their lips together, have trouble with biting their lips for an F or V. So you would perhaps integrate that as an exercise. But it's important, again, to emphasize that these are not just randomly selected without being scientific, and you having seen objective clinical data to indicate that these are problematic areas. Does that make sense?

[0:31:45] MM: Absolutely. I feel like you wouldn't give somebody to do that flat tongue, skinny tongue exercise, if they demonstrate the ability to have a pointed tongue, and use that on command, and they don't have a problem with like R, or that sort of thing. But if they're having that difficulty, then you would use that exercise to help improve that particular muscle function. And then you're going to tie it back to the speech error that they're having, that they need that skill for.

[0:32:12] AM: Right. Exactly.

[0:32:14] MM: I love it, because there is a time and a place for some of these oral motor tasks. But as long as they have a direct relationship back to the functional task that you're wanting to improve.

[0:32:29] AM: Yeah. I think about too, a large number of the clients, we're talking obviously about speech sounds. Things that we're working on when we're addressing myofunctional disorders are not targeting only speech. We're also targeting resting posture, we're targeting what they do when they swallow, we're targeting bolus manipulation. There are various aspects of their swallowing that we're also working on. So the speech aspects are sort of a secondary benefit, but if they have legitimate myofascial disorder, there are going to be some of those vegetative things that are priority in your treatment plan.

[0:33:12] MM: Just for like a little recap, so we did have Linda D'Onofrio and Kristie Gatto on, they kind of gave that overview. Just like as a reminder, we have respiration, is like the primary function of the cranial facial complex. If we're not breathing right, that's got to be priority number one. And then we go into swallowing function, and then speech is at the very top of the pyramid of what the cranial facial complex is responsible for. So we will have to check the boxes before we get to that top point on the pyramid.

[0:33:44] AM: Absolutely. Thank you for bringing that into this conversation because that is so important.

[0:33:50] MM: It's such a huge piece. Because, yeah, we can't really talk about myofunctional disorders without talking about the foundation, which is respiration, and swallowing, functioning.

[0:34:00] AM: Yes. 

[0:34:05] MM: Can you talk about some of the evidence that there is to support using a myofunctional approach for articulation in the presence of an OMD? Because not all articulation disorders are going to be the result of an oral myofunctional disorder.

[0:34:20] AM: Absolutely. The thing is, the research that's out there has indeed, that supports using these things that we're talking are related to the presence of a myofunctional disorder. They're not in absence of a myofunctional disorder. I will say that this is an area that's not like some of the high-incidence disorders that are in the SLP scope. I'll even say this. Some of the literature that's out there has actually been published in maybe dental journals, and orthodontic journals, then SLP journals. So you're definitely not going to find these large, large number of studies, and then these studies with huge sample sizes that are our guiding our practice, but there are a few. 

I just listed just a few to prepare for this talk. There's one study that took place, I'll try to do these may be chronologically reversed, chronologically. There was a study in 1981. The authors are Christensen and Hanson. So Hanson that I have already mentioned, who gave us the definition of an OMD. The title of their study was, an investigation of the efficacy of oral myofunctional therapy as a precursor to articulation therapy for prefirst grade children. That was in the Journal of Speech and Hearing Disorders. One of the original. Well, the ASHA journal under its older name.

[0:36:01] MM: In 1981, this has been around for so long.

[0:36:05] AM: Yes, exactly. OMDs have been a topic of focus for many, many, many years. We're obviously seeing more attention being given to them recently, as compared to previous years. But these are not a new concept. I've been in the profession Ð and they've been around the whole time that I've been practicing. Then there was another study in 1992, and the title of that is, myofunctional therapy in patients with orofacial dysfunctions affecting speech. Maddie, I'm happy to just share these with you off the podcast too, if you need them for your Ð

[0:36:50] MM: I would love that. Could you hear me writing them down?

[0:36:53] AM: Yes. But for your resources, I can share these. Then the authors for that were Ð but the point is, they found improvements in speech following myofunctional therapy. I'll try to pronounce these, Bigenzahn, Fischman, Mayrhofer-Krammel. That's a hyphenated last name. That's a little more recent study. There was another one in 1995, Gommerman and Hodge. Their title was, the effects of oral myofunctional therapy on swallowing and sibilant production. Very specific class of sounds, but still, they found evidence to support myofunctional therapy for improving speech. 

Then, there was another one in 2003, and it was published, or the author is Ray. I don't have the specific title here, but the takeaway was that adults who exhibit phoneme errors, and reduced intelligibility can improve with orofacial myofunctional therapy. Then there was a another one in 2013 by Costa, Mezzomo, and Soares. The outcome of that with that, orofacial myofunctional therapy may facilitate progress in speech therapy by helping the patients to learn proper phonetic placement for phoning production. The benefit there is placement, but that's what we want. We started early on in our conversation talking about the importance of precise placement, so they can be used as placement as well, even if not directly impacting muscle functions.

Then, more recently, there was a systematic review that looked at orofacial myofunctional therapy and myofunctional devices used in speech pathology treatment. That one didn't specifically focus on speech sounds. It focused on overall improvement. Some of the other things that could be affected by OMDs. The conclusion was that, there are a small number of studies to date that explore the use of devices, myofunctional devices. But there's a growing body of evidence to support the use of orofacial myofunctional therapy within a multidisciplinary team for people with both communication and swallowing difficulties. There was evidence there and that was a 2021 study. One of the takeaways is that, we definitely need to do more research, but we do have the foundation of earlier studies stemming from years ago to show us that benefits have been the outcome of orofacial myofunctional therapy.

[0:40:02] MM: I love it. That's fabulous. Because the evidence is there, even if it's small, but it's there, and it's been there for a while, which I think is really interesting. Let's see. Joanie asked, could myofunctional therapy help patients with Parkinson's who have reduced intelligibility?

[0:40:24] AM: I'll just say that I am not aware of any studies that have specifically mentioned Parkinson's, but I recall preparing for a talk on this topic for a different reason. I did see dysarthria in general, mentioned as potentially being remediated by therapy, orofacial myofunctional therapy. I mean, obviously, Parkinson's does have a type of dysarthria, but I don't know if the type of dysarthria that was talked about in that study was related to Parkinson's. I'm just not familiar.

[0:41:04] MM: I'll also go back to what the Ð Parkinson's is degenerative. But then also, once again, going back to your assessment, what are the deficits that they're presenting with, and is there a way that we could use to Ð is there something we could approach from like a myofunctional perspective that would help to improve that muscle functioning?

[0:41:25] AM: Yes. I've seen just from what I know about Parkinson's in general, a lot of the interventions for that have been more or less compensatory. Like if theyÕre saying, loudness of their voice, getting them to project more, and speak with intent, and like that, as opposed to actually addressing muscle functions.

[0:41:44] MM: Okay. We have about 15 minutes left or so. I know you had a really interesting case study that you wanted to share. You want to go ahead and jump into that.

[0:41:55] AM: Okay. Sure. I'll talk about a delightful little boy, who was seven years old when he presented on my caseload out of parental concern at the time, primarily with his difficulty with R articulation. I mean, most SLPs know that R is traditionally one of the most difficult to remediate phonemes that we can encounter. But he had no semblance of R, so no consonant R, no vocalic R, and no R blend. At the time that his mother came to see us, he had actually had a previous speech sound assessment via another connection. The results of the Goldman-Fristoe showed that he was performing in about the sixth percentile. His sounds in error on that assessment, again, at the age of six, included R, vocalic R, and also L. 

At the time that, basically, between the time he was evaluated at six and the time he was seen at seven, he had shown some improvements, but that R was still a persistent problem. In assessing the background and collecting case history details, I discovered that there was a history of feeding problems. He had actually, as an infant, undergone revisions of his lip and tongue, basically having ties released. Throughout his development, he had had frequent colds, there was at least one episode that he had, what was described as respiratory distress, but he had frequent colds. He had had dental crowning. 

At the time that he came in for the assessment, we also noticed that he wasn't really managing his saliva well. He was doing some drooling and it was significant enough that he'd sometimes like wipe his own mouth. He was aware, but he just couldn't control it. When mom brought him to us, my initial instinct was, I had my myo eyes on, thinking this is a child who has myofunctional difficulties. But the scheduling constraints of the timeframe in which we had to work would not permit me. Like I had already invested a lot of time in conducting the speech sound assessment and collecting this case history. It wasn't until we were sort of in the middle of the speech sound assessment that I realized, hey, we just need to actually do more myo-focused assessments.

I veered from the plan and used the balance of the time that we had to do some sort of myo probes, like myo screenings, and everything, and it did look as though it was myofunctional. So therapy was recommended. Instead of only working on the remediation of the phoneme, we actually implemented a myofunctional therapy protocol. The treatment protocol included tongue, like tongue tension exercises, that flat to skinny tongue that I talked about earlier. Elevating the tongue tip to the spot, actually improving the range of motion of his tongue. We did a lot of interventions for the tongue, we did a few interventions for the lips. Again, just sort of following a very regimented treatment protocol.

In the course of about, I'll just estimate because I can't recall specifically. But I'll say, in the course of about five to five to six months, the drooling had stopped. He was highly Ð he became highly stimulable for vocalic R, and he's super sharp, he was such a brilliant child, that he got to the point that all we have to do is tell him if he ever made an error with an R to go to er. Essentially, we taught via a shaping, or successive approximation approach to move that er into any other R he wanted. So he could do r- red, and make red. Or r- run, and make run. Or her, or mo-ther, basically.

So he got to the point where he was consistently able to make any R that he wanted to. Some, he actually could just immediately produce the standard R without using a shaping technique. But I felt like our mission was accomplished, and we were successful, and that he had no semblance of R in anywhere, any place in his inventory of sounds when he started with us. But by the time he left us, he could do any R he wanted to.

[0:47:44] MM: That's amazing. Did this kiddo need like Ð did he have any airway concerns going on? Did you have to refer to an ENT, or a tongue tie, or anything like that?

[0:47:53] AM: Well, he had the tongue tie, and the lip tie Ð

[0:47:57] MM: Oh, as an infant.

[0:47:58] AM: Ð addressed as an infant. I suspect that some of the concerns that were reported in the history of before he came to us with the chronic colds, and the respiratory might have indeed been an airway, or stemmed from airway problems, but apparently, they resolved.

[0:48:17] MM: Oh, got you.

[0:48:18] AM: So, he was clearly a success story.

[0:48:22] MM: Absolutely. I love it. You said like six months or so. That is a fast R remediation.

[0:48:31] AM: Yes. It's definitely not Ð and it may have been a little bit longer, but it wasn't. It wasn't extensive period of training. But again, he was exceptional in his awareness, once we pointed out to him what needed to be changed. He would catch his own errors. He could self-monitor and start Ð sometimes, even, he didn't know how to revise. He at least knew that they weren't standard, and that's the first step to Ð

[0:49:02] MM: Absolutely.

[0:49:03] AM: Ð to be able to modify.

[0:49:04] MM: You have to get that awareness before we can make any changes. That is awesome. I just love it. Because it's a true testament to Ð we make our speech sounds with our tongue, and our tongue is a muscle. If that muscle needs to be able to shape, and move, and perform various functions, and we need to make sure that they're able to do that. Let's see. Thena have a question. She said, "I have a question related to frontal or lateral lisp and the related tongue thrust, would that be considered an OMD?"

[0:49:39] AM: You wouldn't know only from what kind of error there is. You really have to look at some sort of at least a screening checklist of OMD features. It's hard to put the pieces together. You can't Ð in other words, you can't start with the type of error that you're hearing, and know that this is coming from an OMD. You really engage that client in the assessment protocol, and figure out if there is an underlying OMD that's contributing to what we're hearing with the distortions.

[0:50:14] MM: Do you know of any available screeners for an SLP that haven't completed a myofunctional course that they could use to identify these kids?

[0:50:24] AM: There are a couple of Ð how can I say this? Honestly, there's so much information out there on the web now.

[0:50:30] MM: Very true.

[0:50:32] AM: That, with some careful inspection, you could find something that's out there. I think what's more important, though, is knowing if you find a screener, what it means, like what you're looking for. For example, when I was talking about venous pooling or the allergic shiners, you might see a screening form that's out there. There's one that's put out by the Academy of Orofacial Myofunctional Therapy. It's called a prescription pad. It's a wonderful feature checklist. It has about 32 features that a person who has an OMD could potentially exhibit. But if the clinician hasn't been trained in what some of those things are, they may not readily recognize the feature, even if they have a checklist, if that makes sense.

[0:51:30] MM: Absolutely.

[0:51:32] AM: There are some Ð I'll call them like self-study materials. There are some, like beyond just a screening checklist. There are some tools that are out there that are sort of manuals where visuals are provided, explanations and definitions are provided. So in addition to a screening checklist, you at least have the theory and background for what Ð and the definitions for what things are. So you have a better idea of what you're looking at. And then there are lots of websites that are helpful for giving you visuals and photographs. Like Dr. Zaghi's Breathe Institute, there are all kinds of things on his website that can help what you see in a manual come to life. 

The point is, if you think about what ASHA's statement is to us as clinicians, to ensure that we're ethical, and holding paramount to the client's wellbeing. We don't have to get our degree in speech-language pathology, and our Cs, our entry-level qualifications. ASHA just says that we have to pursue some sort of additional training to ensure that we are competent in what we're doing. That may come in the form of self-study manuals, continuing education classes. It doesn't always have to be in an intensive entire weekend set of courses. I mean, obviously, the more training you can get, the better. But you could start with what's immediately accessible to you, and build your expertise in small successive steps.

[0:53:18] MM: Absolutely. I love that and it's so important too, because I know that I get a lot of SLPs in my area that reach out to me, and they're like, "Oh, Maddie. I see that you're doing this. What do I need to do?" I'm like, "Well, here are some resources." I thought just like one simple answer, but it really is like gathering your knowledge base on building that understanding of what the craniofacial complex is, and what is typical function. Understanding typical has been huge for me.

[0:53:49] AM: The ASHA website is honestly a very good initial source for you to go to, and read up on OMDs, and what they entail, and what an assessment looks like. I mean, start there because all of us have access to it.

[0:54:06] MM: Absolutely. I'm posting these in the chat as well. I have the Breath Institute, I have [inaudible 0:54:12] page on like tongue tie that's super informative, the ASHA portal on OMDs.

[0:54:20] AM: The other checklists that I mentioned is, it's the Academy of Orofacial Myofunctional Therapy. Have you seen it already?

[0:54:28] MM: I think I grabbed it and put it in the chat as well. It's like five lateral tongue [inaudible 0:54:32], that's very Ð as you're saying, very jargony. If you don't know what some of these things are, would be a little tricky to understand. But some of them are really great. Like, are they mouth breathing or nasal breathing? Do they have an open-mouth posture? If they have habits. There are some that are, but still be helpful, I think, for people even if they don't know all the vocabulary on it.

[0:54:56] AM: Yes. As I said, I think it has 32 features. Even if the client only has three or four, you've got insight into the possibility that there could be something in the myofunctional family going on, something in the myofunctional vein going on.

[0:55:15] MM: I love the case study that you shared. Just by asking some questions about what early feeding looked like, about early respiratory infection, then that sort of thing Ð you're able to kind of piece this myofunctional picture together. If there's like an orofacial myofunctional disorder at play, you can find out so much just by talking to the parents and finding out what the child's history has been like up until that point. One question that we briefly touched on, but I just want to make sure we hit home. Is every speech sound disorder a result of an orofacial myofunctional disorder?

[0:55:48] AM: Absolutely not. No. Again, I'll go back to what I've said multiple times on this conversation. We have to look at our assessment. What do our clinical features show? What does the clinical data show? So if you're not seeing evidence of these things, like airway problems, or tongue thrusting, or the adenoids Ð not adenoids, the tonsils being enlarged, we can't see the adenoids, mouth breathing. There hasn't been a history of infant feeding problems, tongue tie, lip tie. Those things that we know are sort of classic features that are associated with OMDs, if we're not seeing evidence of that in our assessment process, we don't really have sufficient data to classify it as a speech sound disorder that could be related to an OMD. 

[0:56:49] MM: I always think about, I have this one patient on my caseload, and she came in, she was highly unintelligible, and so kind of looked at her with my myo eyes. But she has a wide, beautiful palate, her tongue rests up in the palate, she nasal breathes throughout our session, she's not a picky eater, didn't have any problems feeding as an infant. She can make all the sounds in isolation, but then she breaks down the word level. She is like a textbook phonological case. For her, this myofunctional approach where we're working on finding the correct placement isn't necessarily appropriate. She really needs those minimal repairs, and not linguistic approach to build her phonological system. 

I think that one of the biggest takeaways is that, well, yes, we do need to be looking at myofunction. Whenever we have a speech sound disorder, we just also have to remember this is just one piece of that differential diagnosis puzzle. There's still a whole host of other things that could be going on with the patient besides just an OMD.

[0:57:54] AM: Sometimes, relating, or extending what you said, maybe it's not a linguistic, phonological remediation they need. Maybe they just need placement, maybe they need you to show them, you need to elevate your tongue to the alveolar ridge to make your L. You're rounding your lips, you're not elevating. Let's look in a mirror and practice elevating your tongue. In that case, you're not doing it because you think that they're frenulums are restricted. You just see that their tongue is not approximating the alveolar ridge, so they're not getting the standard phoneme. They need a lot of drill, they not need a lot of Ð think about principles of motor learning, they just need to learn to habituate. We've been talking about habits. Habituate those new placements.

[0:58:38] MM: Absolutely. We'll give people just a couple of more minutes to see if anybody has any other questions this evening. But this has been so fabulous, I learned so much from you this evening, Dr. McLeod. I loved the two case studies that you shared this evening. Just really kind of drove home, like how beneficial looking at speech sound disorders from myofunctional perspective can be whenever we are dealing with a true myofunctional disorder. This has been fabulous.

[0:59:13] AM: Well, I'm really happy that you thought enough of me to have me here. This is something I've had a long-term interest in. Like I said, I've been in speech pathology for a long time, and I've honestly sort of always been interested even before science has taken us into other directions with myofunctional, like with the airway, and the appliances, and all the things that are out there now. Back in the early days, I was interested in tongue thrust, when essentially, when you heard tongue thrust, that's what this was. We weren't concerned about some of these other Ð but I've been interested in it ever since then. 

[0:59:55] MM: Well, I appreciate everything you're doing. For anybody that Ð have you had any middle school students with hyponasality, enlarged adenoids that had adenoids removed and resonance improved?

[1:00:08] AM: Honestly, I think I've seen some cases where it might have resulted in some hypernasality.

[1:00:17] MM: [Inaudible 1:00:17] one patient.

[1:00:19] AM: Following the surgical intervention. I don't know if I've seen the opposite. But I would just say, if you have any suspicion or concern that there could be an airway issue, go ahead and refer. You've done your role, you've served your role in making the referral, and it's up to the medical professionals to decide whatever kinds of interventions are needed. 

[1:00:45] MM: Yes. That's always what I say. Refer out, and we can Ð I've done my due diligence if I have referred them out to the provider that can check that out for them. So if you guys love Dr. McLeod, as much as I do, just a reminder that she has been featured on the First Bite podcast with Michelle Dawson talking about myofunctional disorders. They're both fabulous, I learned a lot. Then, she also has a two-hour course on orofacial myofunctional disorders if you want to learn some more. Thank you again for your time this evening, Dr.ÊMcLeod. It was fabulous. I'm so happy that you're a part of this mini-series. I know it'll be very beneficial to the series as a whole. Thank you so much, and we look forward to seeing you next time.

[1:01:29] AM: Thank you, Maddie.

[1:01:30] MM: Of course.

[END OF INTERVIEW]

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[END]
SLPL S11E4		Transcript

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