EPISODE 6

[INTRO]

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

[INTERVIEW]

[00:01:04] MM: Hello. Welcome, everyone, to another episode of Making Sense of Myo. My name is Madi Metcalf, and I will be your SpeechTherapyPD.com host for this episode for this podcast. 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. This evening, Patty Fisher will be our guest, and weÕll talk about how ankyloglossia or a tongue-tie can impact voice and fluency. As a reminder, so this is part of a larger series. So if you have questions about why are we looking at tongue-ties or how is that impacting other areas of our craniofacial complex, you can go back and listen to some previous Making Sense of Myo episodes.

Patty's financial disclosures includes that she receives an honorarium for this podcast. Her non-financial disclosures include her position of parliamentarian of the International Association of Orofacial Myology. She is also a member of the American Association of Speech and Hearing and the American Ð yes, sorry guys. And the telepractice thing. She's also an active in the Ohio Speech-Language-and-Hearing Association. Patricia is a speaker at these organizations, and she mentors. 

For myself, I receive an honorarium for hosting this podcast, and I do not have any relevant non-financial disclosures. We'll be taking questions as they are relevant to the content of our conversation throughout the episode. Then we'll also have a Q&A at the end. So if I don't ask you a question in the middle, we'll definitely get to it towards the end of the episode. 

Patty Fisher currently works with Speech and Language Associates of Dayton, providing services in the Dayton and Cincinnati, Ohio areas. She is certified in Orofacial Myology and Lidcombe, an Australian-based program for children that stutter. Patty has served as an adjunct faculty member at Miami University in Ohio and for the College of St. Rose in New York. She is a fellow and has received Honors of the Association in Ohio. In addition, Patty has chaired the Consumer Affairs, Insurance Initiative, and Student Scholarship committees and was the Director of Public Information. She is a post-parliamentarian for the International Association of Orofacial Myology. She was honored to complete a research project with the Max Plank Institute in Germany on the effects of Orofacial Myology. 

Patty's returning to SpeechTherapyPD.com. She's been featured on the Speech Link Podcast, where she discusses methods to improve parental involvement on teletherapy and of the two-hour grand rounds discussing the relationship between ankyloglossia orofacial myology and voice. Now, without further ado, we welcome Patty Fisher to this evening's episode of Making Sense of Myo. Hi, Patty. 

[00:03:36] PF: Hi. Boy, that was a long way to say hello, wasn't it? Thank you very much. I do want to make sure I am the past parliamentarian for the IAOM. But I'm no longer a parliamentarian. 

[00:03:49] MM: So sorry about that, that I misspoke there. 

[00:03:51] PF: ThatÕs okay. They made Ð you move on. 

[00:03:56] MM: All right. So can we start off by first talking about what is an orofacial restriction or limitation?

[00:04:05] PF: Yes. I'm kind of glad we're going to start there because it happens to be the papers I have out in front of me. But itÕs like that. I think it's a good place to start. A lot of people only look at like, ÒOh, tongue-tie,Ó and that's about the only thing they're thinking about. But really, in our history as speech pathologists, we all know so much more than what we give ourselves credit. The things that when I went through school, we didn't spend as much time as maybe I would have liked to learn how to do a good orofacial examination, and I kind of had to learn along the way. Maybe I stumbled a few times, but it has become so important to my overall practice. 

So I want to make sure all of you have the same kind of background or look at it the same way. I know that when I look at the face, I start my diagnostics when the people are in their waiting room. I'm looking at the way they breathe and the way they interact, just the way they carry themselves. So one of the things when we do get into the mouth, we've all been taught to look to see the tongue, to look at the sides of the cheeks, the teeth, the pallet, that kind of thing. But the one thing that no one ever told me to do was lift that tongue and look under it. It was kind of a surprise to me one day when I started doing it. Oh, my gosh. I'm missing a lot of information. 

So the things that I look for overall in my questionnaire, I start to ask about how the child fed. Were they bottle-fed? Did they have nursing? Were they Ð did they have a [inaudible 00:05:41]? Did they have thumb sucking? So that would be one of the first things I start. That's a possible impairment or an obstacle. I look then to see if they have any upper airway disorders such as allergies, nasal congestion, obstructions, that kind of thing. As I'm doing the diagnostic, I'm working with the parent every step of the way. 

The third thing I look for is trauma or disease. I'm looking to see if there's something like thyroid issues or cancer, those kinds of things. You think maybe that wouldn't happen with a child. I will tell you, the first assignment I had in the first class I did an evaluation, the first child I met ended up having cerebral palsy. About three children later, the child was perfectly normal as far as I could tell, but he couldn't hear.

The fifth child I saw, I put in my little otoscope, and I saw that the light reflected back at me through the ear, there was cancer all through the jawbone. It turned out that these three children, families, I had to call my first night, and they were all related. They thought this new speech therapist within their town was nuts. But all three of those cases, it's true. That's what they had. But my evaluation, if I hadn't been looking for all those things, I really shudder to think what if I had missed. So it's sort of an important part. 

Even though we don't expect those traumas, even in young children, I look, of course, for the older people. I look to see if there's a history of BellÕs palsy, maybe multiple sclerosis or even vocal cord damage. But that's easier to identify in an older patient. But when you're looking for children, you have to make sure you're looking for the traumas as well. Another possible ideology or an atypical or what you might call an obstacle would be large tonsils or frequent sore throats, infections. It's funny because lots of families will say, ÒOh, no. We don't have those kinds of things,Ó because they've only been to the doctor six or seven times that year. In my mind, I'm thinking, ÒOh, my goodness. For every episode, that's maybe six weeks of affected area where they're not breathing normally.Ó 

So I really go through that kind of thing as well. I look for the thumber, thumb, finger, or tongue sucking. Most people, I think we're not trained to look for the tongue sucking, but that's the one that's hidden, and that's the hardest one to change. Then I also look for the structural limitations. That's where, of course, our tongue-ties come. It's interesting because when I first started, I had to see the tie under the tongue, and I had to see the heart shape and all the things that were normal characteristics. 

But as I've started to work, I now can look at the top of the tongue and see the dimple that tells me, ÒOh, there's a restriction in the middle of the tongue.Ó I almost can hear when they talk now because I've gotten so accustomed to it, and I'll hear that they don't lift the middle part of the tongue, or they talk using the middle part of the tongue instead of the tip. As you get into orofacial myology, your abilities to be a speech pathologist and to hear and to identify those errors is going to sharpen. 

I wonder now how I ever survived before I started to understand this complex. It's amazing to me, but yet I wasn't trained. I don't think many of us were trained to pick that up early. I don't know about you, Madi. 

[00:09:17] MM: Yes. No. I had no idea. I remember like one of my first patients. I was like sitting. I was like [inaudible 00:09:23]. They go [inaudible 00:09:23]. They go [inaudible 00:09:24]. They go [inaudible 00:09:25]. They were like thrust their tongue forward. I was like there's something going on. This kid is not able to like find this bracing. So that was the first patient that I started looking at the mouth a little bit differently. But I just learned, you know. You just work on the sounds, but there's so much more than just the sounds. 

I love that you already touched on some of these kids that have tongue ties are not moving their tongue the right way, or they're using the mid-blade to say some of those like lingual alveolars versus the tongue tip because that's been a huge kind of reoccurring theme is that we have to not just judge articulation based on the acoustic property but also what the placement looks like because that is a huge piece of this puzzle. 

[00:10:02] PF: Right. You know what's also interesting, and I wonder if there are other speech therapists that will admit this, because I used to supervise at the university and, obviously, clinic, looking at diagnostics, and I can remember almost all my bright, beautiful graduate students. They come in, they give a beautiful articulation test, and they were accurate, writing and doing all this. They'd say words, but not once would they look up. They just write what they heard. So they never got the advantage of being able to look. I probably was doing it, too. But until I saw my students do it, it didn't dawn on me that, oh, my goodness, we're missing a whole show right in front of us. 

[00:10:43] MM: Right. Absolutely. 

[00:10:45] PF: It was interesting because I think that's normal. I think we do that. We don't understand that we should be looking, listening, and that the function is just as much important as the structure. But those are the basic ones that I look at, as far as looking for the tongue tie. One of the things that was in occurrence to me, when we're talking about having articulation disorders, I think that one's easy for people to understand that if you have a restriction, you're going to have that affect your production. 

But I can still remember. I would go and where I went to school, we had really great professors. They were the kind of people I was a little bit afraid of, but I can still remember one. Particularly, Dr. [Cowstall 00:11:34] would always talk about the function, the function, and all these kind of things. He was always into research. I remember when it dawned on me, when I finally understood the words that this oral complex, primarily, the function of it is to breathe or for [inaudible 00:11:53] to eat. These are biological factors, and you have to have those to live. 

I remember thinking, ÒYes, that makes sense.Ó But the overlaid or the secondary functions, of course, were speech, voicing, using your mechanism to play an instrument, all those, or singing. We as speech pathologists sometimes grab the dog by the tail, and we're working on the sounds or weÕre working on the voice. Or we're working on the fluency before working on the mechanism that making sure the primaries are working correctly. I remember when that dawned on me. I thought, oh, my gosh. This is really hard to understand that I would have missed that, but no one never kind of directed me that way. All they would talk about was the function, but they never told me the differences. I'm sort of a you got to give me the dots or the crumbs or I won't get there. I need everybody to give me a little help. 

[00:12:51] MM: Absolutely. Don't we all?

[00:12:53] PF: Yes. So that's where I am as far as the diagnostic. But one of the things that it led me to was Ð and the reason I am doing a lot of different diagnostics, I work with a study group of my dentist, orthodontist, and the ear, nose, and throat specialist in our area. I was fortunate to be invited to come to it. Then, of course, because you're invited, you better produce something. I remember sitting down at the table, and they were all giving something, and I thought, ÒOkay.Ó I scribbled this out one day and put it up, and it was Ð they liked it a lot. But I don't know if you've ever thought about the things that we know as speech therapist and we look for. 

I know that I always was aware of things like apneas, the OSA kinds of things, the breathing. I would consider that, and I did a chart to show them the difference between having upper respiratory resistance syndrome and what ends up to be OSAs. They just loved it in the fact that it kind of gave them something that we, when we're looking at young children, look at and then what they would see that turn into as adults. It was an accident. I was trying not to look foolish, but it has become a pretty good chart, and I use it now more and more. I think sometimes the things that we make out of haste turn out to be pretty good, so. 

[00:14:27] MM: I have one question about diagnostic. You mentioned that heart-shaped tongue tip. Do you have to have that classic heart-shaped tongue tip to have a restricted frenum?

[00:14:37] PF: No, you don't. I think that's the important part that I want to make sure everybody understands. We know what we classically see as a tongue-tie, and we know what we're looking for. Yes, those are usually characteristics, or there'll be a restriction. But what's interesting is that not all restrictions need any alteration. I have a tongue-tie. It's a posterior tie, but I can do what I need to do. I think because I do the stretching exercises with my clients maybe 6 to 10 times a day, I may have a nice stretched mechanism. 

But there was a period of time when I went, was younger, where they told us, ÒWe didn't do any tongue clippings or we didn't have anything like that.Ó But I think we have to come to a point where we realize sometimes someone needs a restriction relieved, and some of them don't. You got to know the difference, and you got to work with that. I hate the idea of one-size-fits-all for anything. 

[00:15:40] MM: Absolutely.

[00:15:41] PF: So I know that when I get my referrals, one of the things Ð most of my docs and I get a lot of referrals from oral surgeons now. I'm surprised. They've kind of jumped on board and want a lot more. Once I was able to describe to them that I try to introduce to somebody who might be a candidate, we do volitional exercises to see what they can do. Then I move them into neuromuscular exercises. See what outside influences can help them. The third level is I work on the stretches. I like very much to have the doc kind of go through it, too. 

Just recently, I had one of the dentist who's just a phenomenal dentist brought their child and sat in on every session. Then unbeknownst to me, they went and gave a talk at their study group, their private study group, and explained that you can't just read about this exercise and do it. There was so much more about learning how to move and what to check and how to stabilize the jaw. I don't think I could have ever done it if she hadn't sat there and watched every step. Then she turned to me three different sessions. She says, ÒIf I weren't used to being in a person's mouth, I couldn't do this, and I couldn't understand it.Ó 

Yet we have a lot of people writing page after page, ÒHere's your exercise. Go home and practice it,Ó instead of learning the actual step and the movement. ItÕs amazing to me, but that's what's going on. So anyway, I'm working more and more on trying to do those volitional exercises, the neuromuscular, the stretching because they are the same exercises you need to do when you recover. 

[00:17:32] MM: Would you Ð I know this wasn't one thing that we talked about, but you've piqued my curiosity. Could you explain the difference between these volitional oral motor exercises versus the neuromuscular reeducation exercises or the neuromuscular?

[00:17:44] PF: I'll try. I don't know if it'll make sense, but volitional exercises are when you are teaching your client or asking them to do something that they have complete control over. So like lifting and putting the tongue down or in and out. But I teach them so that they have the jaw stabilized, and they're showing the upper teeth. That increases the musculation of the risorius muscle, the buccal muscle, and the masseter muscles. They voluntarily control the movement of the tongue, and that's the range. 

Now, after you have a release, within the first 24 hours after that release, they have to do volitional or voluntary exercises. But nothing will hurt because they will only do what they can control and what they will feel comfortable doing. The next level is the neuromuscular, and that's where you Ð you probably remember when you used to do these exercises where your own muscles against your own muscles to make them stronger or that kind of thing. Neuromuscular is where you are using brushing, icing, or tapping. All the muscles are around the main muscles respond and support the main muscle. So that's why you're doing it. You're helping the muscle learn. 

Like when they're going to Ð after they've had a release, they learn to point their tongue with aid that you can physically give them, and they get the feedback or ice so that they feel cold and they move their tongue to cover that position. It's a very interesting response. I'm so surprised at how well they can do it. ItÕs one of those um exercises that the parent really participates, and they really start to understand the movements. 

Then the last level, of course, is where we do the stretchings, where I go in to the molars, under the tongue, and we trace along the bottom and up the side of the frenum. TheyÕre like Js on both sides. Then I do it down the front. But I try to teach the parent, and they're the one doing it with their child. Or the adult does it for themselves. It gives them power. They also know. I do this volitional exercises within 24 hours. I do the neuromuscular within three days. I start in with my stretching again within five days. When the diamond forms under the tongue after the release and falls, then I start the front stretches.

There is timing, and it just allows them to feel comfortable. They know what to do and also what they should eat or shouldn't eat kind of thing. So that it's easier for them to get through this session, through the period, and they recover quickly. 

[00:20:43] MM: Elizabeth asked if you have any resources for learning about the process on volitional muscular, the neuromuscular reeducation exercises. 

[00:20:52] PF: I've got something I kind of wrote up. It will help you. It'll guide you a little bit. But I don't know if you took any courses. Like when I got my com, I had to research it. I looked up to see who had done and written the neuromuscular exercises. It was Dr. Falk. I looked up his original studies, and I can get to that information. You can look at it. It's hard to read. I think it's very short, but it's hard to read because it was written so long ago. But the exercises are good, and they're helpful. 

What's Ð their results were kind of impressive because anyone who went through that program that they did, they don't report very many relapses because people just Ð the muscles responded. The supporting muscles helped. I don't always use it, but I use it when I have to. It's particularly helpful for kids or people who have other challenges such as some neuromuscular or even some of our challenged kids that we would be afraid to try these exercises, but the other kinds of things. 

I can give you that, but you look up Dr. Falk. ItÕs Marvin Falk, and he did the information. I know that originally, when they brought neuromuscular exercises over here, we had Ð they were taken from Australia, and there was a nun who was a nurse who did a lot of those kinds of exercises on patients that had polio. Then they brought them over to the United States somewhere in the 1930s, 1940s. They started doing those kinds of exercises. 

Particularly, Kaiser, you probably remember that name, he had a son that had polio, and he needed the exercises done. So he backed it, and there was a lot of money put in from Kaiser Industries to Ð that neuromuscular thing started because he had a son that was involved with that kind of problem. 

[00:23:04] MM: Very interesting. 

[00:23:05] PF: I didn't mean to get off there. That's a little tangent, but anyhow. 

[00:23:08] MM: I know. Is it F-A-U-L-K?

[00:23:12] PF: F-A-L-K. I think it is. 

[00:23:15] MM: Okay. 

[00:23:16] PF: It is Marvin Falk, was the one who wrote it for speech. See, what happened is this. That particular Ð I believe it was in Michigan, and he was working with really challenged populations. People had like Parkinson's. They had different really challenging issues, cerebral palsy. They were doing those kind of exercises to help them to control their saliva and swallow better. 

Then one day, just out of the blue, somebody said, ÒYou know, I wonder. It works so well on our challenged population. What if we used it on just populations that had normal muscle development?Ó Sure enough, when they tried it, it worked, and it worked twice as well and probably twice as fast. It makes sense, but he was a director of a speech program. I know that's how it got introduced into speech is from him. That's all I know. 

[00:24:12] MM: So interesting. I did not know that. 

[BREAK]

[00:24:14] ANNOUNCER: Are you taking advantage of our new amazing feature, the certificate tracker? The free CE tracker allows you to keep track of all of your CEUs, whether they are earned with us at SpeechTherapyPD.com or through another provider. Simply upload your certificate to your registered account, and you're all set. So come join the fastest growing CE provider, SpeechTherapyPD. Com.

[INTERVIEW RESUMED]

[00:24:42] MM: Yes. Katie or Kate, I see your question. I'm also having a hard time finding it. I was going to put a link in the chat if I could find it. But if you could Ð would you be able to email me a resource on Marvin Falk after we're done, Patty?

[00:24:54] PF: Yes. It was written in 1977. His article was written in the IAOM research journal in 1977. That's all Ð that's where I found it. 

[00:25:04] MM: Perfect. Thank you for that. I'll put that into the chat really quick for everybody if they want to look into that, and I'll try to find it as well. Okay. So we've kind of talked about how ankyloglossia can impact speech. That mid-blade can be down. We are not elevating for those lingual alveolars. Are there any other impacts we should know about how ankyloglossia can impact speech?

[00:25:27] PF: Well, I particularly notice it in working with my voice clients and because I actually had one of my surgeons who had done a tongue release on. It was a young man. He was, I want to say, 20 years old. Yes, he was 20 years old and he was about 6'1Ó, very developed young man. They had done the tongue release. But all of a sudden, and he didn't have any of the preparation or anything like that. Because at this time, this surgeon wasn't thinking there was any related issue. But after they did the release, he sent him down to me because he said something's wrong. 

Sure enough, when I saw him, there was something wrong. He went through all the tests. Again, I didn't know what he was looking for. At the very end of our talk, the young man said, ÒGoodbye, thank you so much.Ó It suddenly dawned on me that his voice was so weird for a six-foot-tall 20-year-old man, young man. To talk like Minnie Mouse was very disturbing. I brought a sample of that, so everybody could hear it because the release had already been done. The family and the doctor expected the voice just to get better. They never really thought that they were going to have to do anything else. 

Well, because it didn't get better and he still sounded like Minnie Mouse, he had the tongue released, they sent them to a speech therapist, not even somebody they knew very well. To make things more difficult, as you can imagine, the surgeon came down to watch me to see what I was going to do. This is kind of scary because I didn't actually know what was wrong until I had a chance to work with them. But I brought the sample to show you what he sounded like on like the second day after evaluation and then what he sounded like by the time he had been with me for six weeks. 

If you guys will bear with me, I'm just going to let you listen to it and see if you can hear the difference of helping this person relocate where his larynx was because the tongue tie had been so tight. He felt more comfortable in a high position, and it never would have dropped because he just felt that was the right place to be. All right, I'll pull this up for you. I know that it's going to be a little difficult maybe for me to get the sound, but I want you to do the best you can to listen. Here's what he sounded like at the beginning. 

[00:28:06] MAN: Emma Oliver is approximately 11 years old. As many other adolescent girls, Emma is openly concerned about her appearance. Every afternoon, Emma asked to be excused to the ladies room to ensure that everything is just so. It is unacceptable not to be one of the in crowd.

[00:28:24] PF: Now, I don't know if you can remember, six-foot-tall 20-year-old male. This is what he sound like by the sixth week. 

[00:28:32] MAN: Emma Oliver is approximately 11 years old. As many other adolescent girls, Emma is overly concerned about her appearance. Every afternoon, Emma asked to be excused to the ladies room to ensure that everything is just so.

[00:28:48] PF: I want to remind you listen to what he sound like when he first walked in. 

[00:28:52] MAN: Emma Oliver is approximately 11 years old. As many other adolescent girls, Emma Ð

[00:28:58] PF: I think that's a dramatic difference, and that is definitely related to the oral motor issue. 

[00:29:06] MM: Do you think that this could also play a role, well, with muscle tension dysphonia? 

[00:29:10] PF: Oh, I'm sure. I'm sure. I just know that this was very interesting to me to see the change and what it did for this young man as far as overall presentation in life. I mean, he said to me after we worked, one of the things he said, no one had ever referred to him as sir in his entire life. They always called him ma'am. When he went through and he got a soda or something, they would look at him like there was something wrong. It was pretty amazing. It was dramatic. 

[00:29:47] MM: Wow. That is really amazing. So we have a couple of questions about treatment. Elizabeth and Kate were both curious about if you could share some of the techniques that you used to help facilitate that change. 

[00:30:02] PF: Yes. I'm going to play a little bit of some of the things that helped with that. I don't know if it's going to help you enough because I know what I'm looking at, and you may feel kind like I'm just talking. But I want you to have an idea what it's like. I did help him by actual physically allowing him to feel his own larynx and then notice what it was like to bring it down to a different position. I use a lot of Joe StempleÕs work. You'll see him on the ASHA register. I use a lot of Melvin Hyman stuff. HeÕs from Bowling Green State University, those kinds of things. 

But I'm going to see if I can play a little bit. Here's the fourth day of treatment that I had with this young man. I know it's boring because youÕll think, ÒOh, my gosh.Ó But I want you to Ð treatment isn't always entertaining, but this was a good treatment session you'll hear. 

[00:31:02] PF: Mi, ya, me, ya, mi, ya, me, ya, mi, ya, me, ya, ma. 

[00:31:08] MAN: Mi, ya, me, ya, mi, ya, me, ya, mi, ya, me, ya, ma. 

[00:31:13] PF: [inaudible 00:31:13]. 

[00:31:15] MAN: [inaudible 00:31:15]. 

[00:31:16] PF: [inaudible 00:31:16]. Ma.

[00:31:21] MAN: Ma.

[00:31:23] PF: Mi, ya, me, ya, mi, ya, me, ya, mi, ya, me, ya, mo. 

[00:31:28] MAN: Mi, ya, me, ya, mi, ya, me, ya, mi, ya, me, ya, mo. 

[00:31:32] PF: So there you're playing with the mechanism, and you're helping him learn his range of voice. But he couldn't get there. What was interesting, of course, since I got the female voice, it was harder for me to get down to that register. But it actually turned out to be a good thing for me to be his therapist because I wasn't perfect in the way I produced my voice, and it gave him hope. When he started to get stronger, you could see it in the way he responded. He thought it was interesting. 

Here's another take from one of his therapy sessions, and I want you to listen to it because he's analyzing. This is right as he's changing his voice. 

[00:32:13] MAN: [inaudible 00:32:13].

[00:32:17] PF: Now, can you do it with the opposite and have that same stability and not move the jaw?

[00:32:21] MAN: [inaudible 00:32:21]. 

[00:32:25] PF: Excellent. Now, look at yourself as you do it and see if your jaw is moving. If it is moving, just move Ð put your finger here at the chin to help you remember. It's just the tongue that moves, just for this exercise. 

[00:32:37] MAN: [inaudible 00:32:37]. 

[00:32:44] PF: Right. Now, smile. Aha. Did you catch a mistake there? What happened? Tell me what needed to change.

[00:32:51] MAN: Well, usually, when I smile, I tend to push a lower jaw forwards. I just push it back. 

[00:32:58] PF: Yes, instead because you're used to it with your tongue-tie, [inaudible 00:33:02] your chin. But you really should be bringing the back teeth together nice and gently. 

Did that make sense? I'm just giving you that as somewhat of an example. I was going to show you or play for you another tape that I have. ItÕs not voice, but this is to drive home the articulation situation. We have this young lady who was in speech therapy since she was two. I want you to listen to the way she sounds, and I want you to listen a little bit to her story. Then I want to tell you something sad about not accepting orofacial myology in our society. But I want you to listen to her first. I'm going to move this. I'm going to move this up here. Listen. 

[00:33:48] WOMAN: [inaudible 00:33:48]. 

[00:33:53] PF: Okay. All right, how old are you?

[00:33:56] WOMAN: Eighteen. 

[00:33:57] PF: And where are you going to be going this fall?

[00:34:00] WOMAN: Miami University in Oxford. 

[00:34:02] PF: Okay. Can you tell me a little bit about what vacation you're going to be taking shortly?

[00:34:07] WOMAN: We are going to the Mena convention in Dallas, Fort Worth. It is five days long over the Fourth of July week. 

[00:34:17] PF: That'll be fun. What did they do there?

[00:34:21] WOMAN: ItÕs, you know, those like [inaudible 00:34:23], so people hang out and play games and just talk to each other. [inaudible 00:34:26] and things and then like the things called special [inaudible 00:34:29] that like people can like hang out in different suites and stuff. It was like a teen one, so we have a scavenger hunt and that kind of thing, and games, and stuff. 

[00:34:42] PF: Sounds good. 

[00:34:43] WOMAN: Yes. 

[00:34:43] PF: All right, I'm going to ask you again. Can you give some advice to those students who are in high school that you would think they should keep in mind?

[00:34:52] WOMAN: Just [inaudible 00:34:52]. Do [inaudible 00:34:55] time and don't be mean to teachers, even when they dissolve it. Just behave yourself and do your [inaudible 00:35:01]. ItÕs all fine. 

[00:35:04] PF: Okay then. Thank you very Ð I want to ask you. Is it all right with you if I videotape you to share with others, so they can learn a little bit about this?

[00:35:12] WOMAN: Yes. 

[00:35:14] PF: Have you ever worked on your swallowing or any of that before?

[00:35:17] WOMAN: No. 

[00:35:18] PF: Okay. What have you worked on before? Sorry. 

[00:35:21] WOMAN: Just the S sound and SHs, the big ones. I've done a lot with the all sounds but not gotten it yet. 

[00:35:30] PF: Okay. So this is first time you worked on this swallowing and that. Okay.

[00:35:34] MM: Since she was two. 

[00:35:36] PF: Since she was two. Now, let me Ð

[00:35:37] MM: Oh, my goodness. 

[00:35:39] PF: Let me tell you the sad part. I know that at the time, I was just Ð I was a private therapist and, of course, I wanted to help her. But I was sure she had a restriction in her tongue. But she was on full scholarship, and she went off to the university. Of course, she got free therapy. They went back to the same thing they'd always done. She never got anything changed. 

In her IEP, I happened to come across the one that was written at school. Now, obviously, she's very bright. She's Mensa, so sheÕs a bright kid. It said in there she was so smart, she didn't need to worry about speaking articulately. It was really sad for me. I didn't find that. Of course, she moved to another facility. But my point is they took her as far as they could and the therapists that worked with her in my mind were the best therapists I've ever met. They were wonderful, and I had the deepest respect for those people. I honestly thought they did wonderful work. I have no question about that. I think it was the fact that it was unusual, and I think it was posterior tie. I don't think anyone, I don't think the doctors saw it. I don't think anyone really caught it. I don't think there was anything wrong with that at all. That was just something maybe they should have known about. 

But like we've talked before, we weren't trained. So I don't Ð I think that they were fabulous therapists, and I think they did a wonderful job to do as much as they did. Where I think the mistake occurred in my mind is she went into a program that's an excellent program. But, again, because they didn't look for the tongue-tie and didn't know about the Ð that it didn't have to show on the tip of her tongue, again, the training. Maybe we didn't have the training. So I can't say anything bad about any professional. I think they all did their job. I think they all did great. 

But I'm still kind of a lot Ð I have a little bit of guilt thinking I didn't know because she wasn't on my case. Who do I tell? It was one of those things where she passed through my life, but she made a big mark. I'm a better therapist for having met her. I really am. I don't know if any of you have ever had that person come through and you realize. Wow, wow. 

[00:37:52] MM: Oh, yes. 

[00:37:54] PF: Are there some other questions I need to answer here? I see there are some Ð

[00:37:58] MM: Yes. We do have one. The similarity to those neuromuscular exercises we were talking about in craniosacral therapy, if there's any similarity between those. 

[00:38:09] PF: I think there is, and I think we can work fairly closely with some of those. I've only approached it from the other end and I do have a sacral therapist I work with and I think she's wonderful. But I'm not trained there and I'd like to be trained better. 

[00:38:28] MM: Yes. I know in the episode with Christy Gado, we talked a lot about how the craniofacial complex is highly impacted by the body. So anytime weÕre working with tongue-tie releases or Ð I don't know. If you see any postural things going on with your kid, I was always referring out to some sort of body work like a craniosacral therapist or PT, chiropractor, things like that. 

[00:38:53] PF: Yes. I'm lucky in the fact that I have the oral surgeons and the orthodontists that I'm working with. We do have a craniosacral person that is really good. For whatever reason, I don't usually interact with her, as much as the others. Then they interact with her. But I would like to work more with her. I think it's the right thing to do. 

[00:39:16] MM: Okay. Then Lori said, ÒI agree. I'm starting to work with craniosacral therapists and OTs and a local orthodontist. I'm looking forward to it.Ó Go, Lori, building that interprofessional team. 

[00:39:28] PF: Build your team. 

[00:39:29] MM: Yes. Love it. Okay. So how can Ð is there any Ð I know this is a really big question, but how is it that something that seems so small as a tongue tie can impact respiration, speech, and swallowing? Like how does that little string do that? 

[00:39:54] PF: It's what you do to adjust to it. Each of us Ð

[00:39:58] MM: I love that. 

[00:39:59] PF: I think that's Ð you don't Ð you wouldn't have any response, and you wouldn't do it unless there was something that got in the way. Oh, somebody found our Ð

[00:40:09] MM: I was trying so hard. Thank you, Elizabeth. I'm sharing to everybody. 

[00:40:14] PF: Great. Thank you so much. But I do think that's it. We accommodate, and we do this in everything. I know that I tripped over one of my grandchildren, and I broke my arm. But I compensated on my left side, broke the right side. My neck, my shoulder blade, my arm, my whole breathing, and my walking was affected by it. But it wasn't this that was really the problem, the break. It was what I did to respond to it. I think when you're restricted, you do unusual things. 

Like when a baby's born, we all have a tongue thrust. Every baby, if you remember, they have that look [inaudible 00:40:56], and the tongue's coming out as cute as can be. Sometime before the age of maybe 12 months, 15 months, it moves to the upper place [inaudible 00:41:05] instead, and that's where it's supposed to be. But if there is a tie or a posterior tie, it continues to go forward, usually. Then you add a bottle or a nipple or a thumb or a blanket or whatever on top. You can't get up, so you're compensating from that very early time. Then you create all kinds of things around it. I believe that's the pattern that usually happens. 

[00:41:30] MM: Yes. So I know there's an area that you've been kind of digging into, and that is how ankyloglossia is potentially related to fluency. Would you like to share a little a bit about that?

[00:41:43] PF: Well, I have some ideas on that. I'm not sure that everyone will jump on board, but I do think in all the experience I have with fluency, I watch those kids more often than not. They're the ones that really struggle with a full breath. They struggle with placement of where they should be just at relaxed state. They're the ones that if they get into something, they struggle with it and can't easily move from one to the next.

I have a little video of somebody that sort of started me thinking about this, and I think it's really interesting because we learn a lot about fluency. But I just gave a talk this summer, and one of the things I learned is that we're all scared to death of it. A lot of us are because we don't know what to do with what we know. We're afraid we're going to make things worse because we're asking them to do certain things like move slowly or breathe deeply or whatever. I'm going to show you a little tape, I hope, or let you listen to something. 

This is a soldier from one of the bases that I've been working with, and I just want you to listen. Then we'll talk a little about his motor movement. He's not Ð this is not an improvement tape. This is just something for you to listen for when you're working on fluency. 

[00:43:18] SOLDIER: Now, the wind and rain could not get in the house. With a nice place to live in and give food to eat, they lived a good life. One day, when the son was digging in his garden, he found something that looked like [inaudible 00:43:39]. He took it to his mother to fix dinner in the house. 

[00:43:46] PF: I don't know how that impacts you when you listen there to him. But you can hear him motorically. He is cutting off his own air. He doesn't allow flow. He's afraid to allow that. Yet when you put this same person into a position where like the feet are straight, his body is straight, he's breathing just fully in and out, his speech almost immediately starts to flow. Especially notice that with junior high and that kind of thing. ItÕs the same kind of therapy you always do. But add Ð and I don't know if you guys are familiar with [inaudible 00:44:35] and Nina Reardon, Scott Yaruss, all of those wonderful fluency specialists. They talk about fluency shaping, stuttering modification, holistic approaches, and that there are four stages they go through. 

First, you establish fluency skills. You teach them in a highly structured rehearsal. Then you stabilize by using the fluency like reading and monologues. Then you start to transfer. The child works on maintenance all the way through. The goal is never to be fluent. The goal is to modify, to shape, to allow your flow. ItÕs really interesting because it's in everything with that, and it's amazing because I've seen real improvement in all the therapy I do with my fluency cases. Once they feel like they have some control. 

Again, think of the biological, the function of the breathing, and the function of the mechanism is to chew and eat and swallow or to breathe correctly. If you work with those things, you're taking all the pressure away from the communication. They get that, and then they start back building up their strength and using it for communication. ItÕs just life-altering to them. I wish I had a few more things, but one of the things I found with the young kids that you can use just starting tomorrow, I used a lot of message therapy. That was Dr. [inaudible 00:46:21] message therapy. HeÕs from Canada 1984 somewhere there. 

But anyhow, if you are using these techniques and you use message therapy along with it, you can immediately start transfers. For example, you have Thanksgiving coming. So you give the young child a turkey message to deliver and on a little turkey. All they have is they take that message to mom, and it says, ÒDad wants you to ÐÓ That's it. You're supposed to say it with your airflow. It's very interesting because you can change your messages every month. You can have a Christmas message or a Christmas tree message or a snowball message. Or you can have a Valentine message or a leprechaun message, just so that they can start to use immediately delivering something with airflow. It starts just at the word level and then phrases and then sentences. 

ItÕs very interesting because it takes in all the characteristics we want. You focus on the message. You develop the message. You deliver the message. You plan it. You consider your pragmatic elements. Then you build cognitive awareness. Guess what. Then you have introduced the motor, easy planning. It's really Ð we're so much smarter than we think. If I say nothing else, the one thing I have learned is that as speech therapists, we have a lot of knowledge. We're trained so darn well. We've got so many things, but it's hard for us to get that message across to everybody about we understand voice. We understand stuttering. We understand language. We understand articulation, all those things. 

Yet we're held to the fire in the fact that maybe we don't know one element like at that moment. But yet look at the knowledge we have. I feel very strongly we don't give ourselves credit for that, and that makes me feel very sad because I see it in the school therapist. I see it in the hospital therapist. I see it in the kids I supervise at the university. I can't stress enough that we need to give ourselves a little pat on the back for what we do know and the knowledge that we're carrying. We just have to put it in a different package for use. I worry that we're missing sometimes the boat because we're trying to have Ð we have too many balls in the air. We don't know that we actually have the answer right there at our fingertips. 

[00:49:12] MM: That is sad but encouraging because we do have that knowledge, and we just need to claim that as speech pathologists because we are well-educated. We are always looking to know more and do better and figure out more for our patients and we can do this. 

[00:49:28] PF: That's right. That's right. I don't know if there's Ð we can't get into too many programs with the fluency, but I think that understanding it like you do with the voice. You can see that if you Ð I think so many of the things that we do Ð if we look at the primary function, and we look at the way it's supposed to be working, and we help them be able to manage it easier and keep in mind the goal is to make the mechanism itself work. We're supposed to be breathing correctly. We're supposed to be using the full range of the tongue. WeÕre supposed to be forming our sounds and stuff. But the other thing is to do it at a rate that's manageable for them. I think part of it is that's a self-imposed obstacle because that time management that gets in our way. 

I saw there's a couple questions. I'm getting nervous that I'm not answering questions for people. 

[00:50:36] MM: You're doing great. So we did have a couple people just say that they've also kind of seen that relationship between kiddos coming in with fluency problems. But then they have the restriction. We have one answer from Chabby. ÒWhat should one take into consideration when deciding whether or not to release the tongue on a baby? At that point, it's hard to predict what the ramifications will be.Ó 

[00:51:01] PF: Yes. I think that you have to have somebody who works with babies all the time and working with you. But I will tell you, if they see Ð my personal experience is this. When we catch and we know that a baby has the restriction and that we can do the release and they're very young, I see them recovering faster and easier than anyone because you can immediately put them on the breast. All the exercises that they need naturally occur. ItÕs, to me, like a very, very good thing. 

Where I have trouble and I probably shouldn't admit this but when I see a child between the ages of two and four, and they are asking me if there's a restriction, I'm probably going to say that I probably wouldn't do the release because I don't know that so many of those kids can do some of the exercises. I don't think they can do the voluntary things very easily. They can't follow you. 

[00:52:04] MM: They love the word no. So even if they can do it, they like to tell you no at that age. ThatÕs been my experience, at least. 

[00:52:12] PF: Right, right. I don't think they're ready for some things, especially if you get into oral motor stuff. Really, until they're four or five, they're not ready. However, there are certain things that people can do. If you want to increase their ability to move their tongue, you could put a piece of cereal on a dental floss and have them move the tongue back and forth or up and down, tracing or moving that piece of cereal. That's okay if it's a game. But those kids I'm a lot less likely to, and most of my dogs feel the same way. That's a time when they can work on other stuff. But the release is not as often. It's pretty hard on them. It's hard on moms then, too.

[00:53:00] MM: Yes. I definitely see that in my practice as well. With my providers that I have in my area, typically, after a year, we kind of hold off until they're able to kind of participate in a traditional myofunctional program. Then I do work with a lot of infants at my clinic. So I'll just share one of my favorite assessments. It's the Assessment Tool for a Lingual Frenulum Restrict or Function Created By Dr. Hazelbaker. One of the things that we kind of go off of is if they're having a functional issue at the time of feeding, that appears to be impacted by the frenum. We kind of use this Hazelbaker Assessment to determine if they have the optimal functioning and then what their Ð I like [inaudible 00:53:50] because it looks at structure and function. It kind of asked a few feeding questions as well. So that one's been really helpful for me in diagnosing them in infants and making that decision. 

Then, again, with infants, always made in conjunction with the Ð well, at any age, but especially those babies. Like making that decision with the parents, making sure that's what they want. If they choose not to, which I've had that, finding ways that we can help them compensate through those feeds. 

[00:54:17] PF: Yes, I agree and I love the work that you're talking about there. I think that's very appropriate. One of the things I was going to say, somebody asked a question about the restriction with the Ð

[00:54:28] MM: Yes, on the mid tongue. 

[00:54:30] PF: Mid tongue. 

[00:54:31] MM: Yes. 

[00:54:32] PF: The thing you hear or you see is that a restriction in the mid tongue, there usually will be a little dimple on the top of the tongue. But what you'll hear, of course, almost always there'll be a distortion on the ER and there'll be a distortion on the L. What I found is to overcome that if you aren't going to have a release done right away. If you are, you're going to go ahead and do the volitional exercises, and those things and things are going to improve. But if you're not, one of the things Ð 

I think I learned this from Linda [inaudible 00:55:02]. I'm pretty sure. Or it was [inaudible 00:55:05], one of the two. Anyhow, I just remember that you can still get some good sounds from that and strengthen, so they're ready by just putting the tongue midline wherever it's comfortable, and start by trying to form an SH sound, just shh, and have them feel where the tongue is in the middle of their mouth. You stay there, and you keep doing shh, and have them look at the roundness of their mouth. 

Then you add a vowel with it, and you go, ÒSure.Ó You ask them not to move their tongue at all, and they will get it because their tongue now learns to form. It does work. It was amazing, and I've used it many times, and I thought I meant to thank them, whichever one showed me that. But one of them did, and it does work. It also is an indicator whether they're going to be able to do some range of motion or movement on their own, even without a release. So it's a measurement. It's also a good technique, and the kids love it. Also, that reminds me of an episode of Steinfeld when they used to say sure. 

[00:56:25] MM: So do you ever do a tongue-tie release without doing therapy beforehand?

[00:56:32] PF: I don't. I always do preparation. I've had two people who've come to me after they did their own preparation, and they didn't know what they were doing. Then they were sort of sad, again, that it didn't correct all their problems. The one was that young man that I showed you with the voice. That was an upsetting thing when they found out it didn't correct all the problems. I had one other one where the Ð and it was funny because the mom was so sure that it was going to correct every speech problem. She was very adamantly angry with the doctor that it didn't correct everything. 

It worked to my benefit because that doctor won't even touch anyone anymore unless he has me look at them. You know, itÕs funny that people sometimes think, I don't know, that they think that magic wand will work, and I just haven't found the wand yet. 

[00:57:29] MM: I know. We see that a lot in my clinic where the parents will come and be like, ÒOh, weÕll just get the tongue-tie released, and it'll fix everything.Ó We have to talk, well, the tongue is a muscle, and there's learned patterns, and just because they have the range of motion doesn't mean that they're going to use those new patterns. 

[00:57:44] PF: It sometimes does work that they get better, but it doesn't always happen that way. I think they're Ð it's sad because they do expect a miracle. I haven't seen it yet very often. 

[00:57:57] MM: We have another question, a bit of a case study. So Jennifer says, ÒI'm currently working with a five-year-old who has a tongue and lip tie, and they started to have this dysfluency over the past six months. He also has apraxia. How would you differentiate what is due to CAS versus tongue lip tie in terms of his dysfluencies? Do you know of any research for ties and fluency?Ó

[00:58:20] PF: I think there probably is some pretty good research on that, but I'm going to say something. I hope it doesn't make you mad. I'm not sure it matters if you differentiate or not. I think what matters is that you get in there, and you get the primary function working. I would start right away with the movements that are going to give him the most success. You can apply it to your sounds. You can apply it to this or that later. I would do the things that would allow you to do that release in that I'm assuming that child's over eight but Ð

[00:58:53] MM: A five-year-old. 

[00:58:54] PF: Five-year-old. Okay. But still, you're in the right thing to get them ready and to allow them that release so that they have control over their own mechanism. I would definitely do that for that job. 

[00:59:09] MM: Awesome. Well, let's see if Ð so we will see if anybody else has any more questions, and then we will wrap up. I have one other question. Do you ever see any impacts on lip, like do you ever do lip tie releases?

[00:59:25] PF: Oh, yes. Oh, yes. 

[00:59:26] MM: Yes. What are some of the indicators that a lip tie release is needed?

[00:59:32] PF: I see it in people that if you're working with them, and they tend to cover their lips as they're talking, it will affect your PBNM. But more than that, it's their smile. It'll be an unusual smile. They particularly cover the top, and it's funny because it will affect Ð I don't know. It just affects the way they Ð to bite everything. I mean, you can see it just way they sit at rest. But those are fairly easy to correct, and it's not hard for the kid at all. 

[01:00:06] MM: Well, Patty, this has been so great. I have learned so much from you about ankyloglossia and definitely gave me some really good tricks. I love that idea of putting a Cheerio on dental floss to have them move it. That was Ð I have not thought about that one, and it is. I have a kiddo that I can think of that I'm going to use that next week. 

[01:00:28] PF: Put it here, so they lift. Or put it here. Go side to side. The other thing is just putting it here and have them reach out to touch it because they don't know what straight out means. If they're tied, they arenÕt going to go so far. So you get it real close. But it gives them success, and then they get to eat the Cheerio or the Froot Loop or whatever it is. But it's the beginning of movement, and I've seen a lot of kids. They can get pretty far if you can give them a chance to get that range of motion improvement. 

[01:01:01] MM: Oh, absolutely. Well, this was great. I love that we had on the big points that we do need to do pre-therapy work to get ready for releases. ItÕs not a magic wand. We do need to do some work after in majority of the cases, and then just kind of enlightening us on the relationship between voice and fluency in ankyloglossia, just a new way to think about it. Thank you so much for attending tonight, and we look forward to seeing you on another episode of Making Sense of Myo. 

[01:01:27] PF: Thank you so much. This has been fun. You guys are great. 

[01:01:31] MM: Thanks, Patty. 

[OUTRO]

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SLPL S11E6		Transcript 

	©Ê2023 SLP Learning Series	26