SEASON 11 EPISODE 8

[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.

[EPISODE]

[0:01:04] MM: Hello. Welcome everyone to another episode of Making Sense of Myo. My name is Madi Metcalf, and I'll be your SpeechTherapyPD.com host for this podcast. Before we get started, we have a few items to alert you to. This episode is 60 minutes, and it will be offered for 0.1 ASHA CEUs. Char Boshart will be our guest this evening and she'll share some practical tips for treatment of speech and swallowing disorders from a myofunctional perspective. Char receives an honorarium as a guest of this podcast. In addition, through SpeechTherapyPD, she also received honorariums for her video courses, deep dive courses, and is the host of the Speech Link Podcast.
 
She owns Speech Dynamics Incorporated, where she offers several practical books, audios, articles, and blogs. She has no relevant non-financial disclosures. As 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 and answers throughout the presentation, and then we'll also have a Q&A at the end. So if I don't get to it during the course, we will circle back around to it.

Now, without further ado, I welcome Char Boshart to this episode of Making Sense of Myo. Char is a speech-language pathologist, author, seminar presenter, and president and founder of Speech Dynamics Incorporated. She graduated with her master's degree from Western Michigan University under the tutelage of Dr. Charles Van Riper, the Father of Articulation Therapy. Char began her career in public schools with a caseload of over 110 children. Since then, she worked several years in the public schools, as well as her own private practice, where she treated speech disorders and myofunctional cases of all ages. She was among several early therapists in her certification in orofacial myology from the IAOM. One of the founders of IAOM, Dr. Marvin Hanson was her mentor in myofunctional therapy.

In addition, she was an assistant professor and department chair of the Speech Pathology and Audiology Department at Loma Linda University. Her interest in creating effective therapy techniques has evolved into the development of several practical videos, articles, and publications such as Swallow Works, The Myofunctional Evaluation, Demystify The Tongue Tie and The Easy R. Char is very involved in SpeechTherapyPD.com, and has provided a wealth of information to this platform. You can listen to her Speech Link Podcast. She's been featured on the First Bite Podcast, and has brought SpeechTherapyPD.com several courses, including Creative Language Therapy, Systematic Instruction for Language Delay Children, Complete R Remediation Therapy, Five Super Sound Stem Strategies, The Perfect Oral Motor Storm, and so many others. Now, you get to be on the Making Sense of Myo podcast. Welcome, Char.

[0:03:33] CB: Thank you. Yes, it's great to be here with you, Madi. Thank you.

[0:03:37] MM: Yes. I'm so excited to have you, and have you share on some practical tips. I know that your myo evaluation text and your swallow works text were so helpful to me whenever I was starting off on my myofunctional journey, and I still referenced them pretty frequently. So we'll jump in and get started. To begin, what do you think are a few of the foundational pieces in our field as to why myofunctional therapy is misunderstood?

[0:04:03] CB: Well, I tell you, I have studied that for many years. You and I have talked about The Perfect Oral Motor Storm. That took several years to kind of pull together on the [inaudible 0:04:13] podcast on SpeechTherapyPD, and it's also on my website. It sounds like a commercial, but it isn't, it's totally free. But since that time, I've continued to dig, and there's something that I discovered that was, and is right in front of all of our faces. It's like, why didn't I realize this before? It's something that I'd like to share tonight. It scratches the surface, but I think it sort of seeps down even below that. It has to do with our basic fundamental paradigm, our belief of working with speech sounds. And our paradigm at the very foundation, you can find at asha.org, within the Practice Portal, and I bet a lot of people have been to the Practice Portal. It's under clinical topics and articulation and phonology. 

If you go there, and it's still there right now, and to series of circles, okay, but it identifies functional and organic. Those two terms have kind of been influential through the years, and I think has kind of held us back from growing into other things, and looking at other possibilities. So you have the functional piece, and I actually have it here. The functional piece, apparently for speech, there's no known cause. So if you are doing therapy with a person and you have no known cause, then you only do sound stimulation, or you do minimal word pairs, or maximal word pairs, or something along those lines. Because there's absolutely no other known cause. There's nothing wrong with their muscles, there's nothing wrong with their craniofacial, oral, respiratory systems. There's nothing wrong there.

So you just do the sound stem, and all of the other things from a more auditory standpoint. So phonological piece, auditory standpoint, cognitive, language, and so on. Nothing is wrong with the oral mechanism. So there is that assumption. Then, the other assumption is the organic piece. ASHA recognizes that. You have motor and neurological, and it breaks it down into dysarthria or apraxia, and that's it. Then you have structural, and their idea of structural is cleft lip, cleft palate. Then you have sensory perceptual of just a hearing impairment. Nothing is said there about intraoral somatosensory issues, or intraoral sensory perception, nothing about that at all. 

If you look at any article, and I'm going to say, almost any article that is publicized by ASHA, and they talk about the sensory piece of speech, and it's all focused on the auditory sensory piece, which is very unfortunate. I'm just going to interject here. The mouth interacts with itself, and a form of interaction is really proprioceptive and tactile, but we sort of skirt that, that you have other places around the world, that are really doing some great research. Down in Brazil, there's some good things going on. In Italy, there's good things going on. In Sweden, in Japan, they're really focusing on that somatosensory piece, intraoral piece. There's some really good research. But here in America, no, we just stick with this model.

If you read any of the literature and the concerns that people were talking about in 2008, 2014, 2015, and even now, they talk about, "Well, why would you work with the muscles when it's just functional? You only work with the muscles if it's organic, if you have something. Like it's CP, or something along those lines. It's been identified. If it's functional, why do you work with it? That comes from, at this point in time. From the label, speech sound disorders.

I look in the portable and there's nothing on articulation. Just this, that everything, pretty much today because, like education, like medicine, like psychology, speech pathology is trendy. Where we're at today is speech sound disorders. The sound of the sound. I have read in these articles time and time again, the ones that had concern for working with the mouth. They would say something like, "Well, why would you work with the muscles?" And you cannot break down a sound. So if I say, "Sss." You can't break that down, you can't parse that. So it's the lowest common denominator. 

We have to provide the auditory piece one way or another, okay? Because we're coming from functional, and organic, and myofunctional, which really looks at craniofacial bone growth and oral hard tissue, soft tissue, and all the things that go with it. Even self-imposed, like thumb sucking, or sucking on a pacifier too long, and how that influences the mouth and potentially craniofacial bone growth. The respiratory system and all of those things. I call the mouth and the function speaking, chewing, swelling, all of those things is comprised of a crossroads of disciplines. I'm going to say, it's the most complex function and complex body part that we have. Because the mouth is the only part that interacts with itself, it's the only part that interacts. I mean, you can blink your eyes, you can twiddle your thumbs, but the mouth interacts with itself, so it's unique.

[0:10:31] MM: That is so interesting. I've never kind of put that together, but it's so true. The tongue interacting with the teeth, or the lips working together, or the teeth and the lips. And then just the coordination of how all that flows together with airflow and voicing paired in. That's so interesting.

[0:10:49] CB: Yes. It's how we have looked at. Now, here's another dimension that I want to add. If anybody goes to that portal and looks at it, those are the things, that's what you're going to see there. Okay. Then, I want to also share with you, staying on this just for another minute, or two, or three. I love buying old speech-language pathology books. Okay, I love buying, and so I have a whole library of them. You probably have never heard of the Travis, Handbook of Speech-Language Pathology. I bet you and I bet a lot of people haven't. People my age have, but I actually have it here. I'm just going to show it to you. Okay.

What I want you to see is, I mean, this thing is heavy. It's Handbook of Speech Pathology and Audiology. This is the handbook. Now, this was written, it was published in 1971. It was the beginning and the end of everything that you need to know about speech-language pathology and audiology. Now, they wrote this one, this was the Handbook of Speech Pathology, this was 1957. The only difference is that they added the audiology piece in 1971. Okay. It also is huge. There is a chapter in there on speech and malocclusions. Interesting? Okay. You wouldn't see at anything right now. 

[0:12:23] MM: It's so interesting.

[0:12:25] CB: Yes. Now Ð

[0:12:26] MM: Jonie said that she has that Travis handbook. So one of our attendees does have it.

[0:12:30] CB: Really? Oh, good. Oh, good. Yes, Jonie. A lot of it, I'm going to say, probably 80% at least is still relevant. It's not like the mouth is going to change a whole lot. I mean, there are things research and things that we do, and we'll refine what we think of speech, or what we think of the mouth, or the whole functional system. But the mouth isn't going to change a whole lot. In this handbook, there's a chapter, Chapter 33, and it was written by a lady named, Margaret Hall Powers.

I'm just going to share a little bit of this because it gives history. The point that I want to make is, okay, this was 1957, and they talk about functional and organic. Okay? We're still there. We haven't moved off of that dime. That's the lens that we continue to view, speech, and oral functions. I have this piece pulled up here. The term functional, and this is according to Margaret Hall Powers in the Travis handbook, originated from the field of medicine. We get a lot of information, a lot of terminology, evidence-based practices from medicine. That's why you have the three things, and why that one, look at the client, and ask the client what they want, and all of that. That's why that really doesn't fit. Okay? Because we got that from the medical field. Okay. 

It originated in the field of medicine, it was adopted widely in speech-language pathology. The term functional, she says, is synonymous with non-organic, and some refer to functional as nonstructural. That was our foundation, and we haven't let go of that. We haven't let go of that. I think that a lot of it is just our fundamental paradigm. That is such a mindset, and especially our researchers, and a lot of individuals that just don't do therapy, and maybe they don't realize that, "Hey, even if I'm doing minimal word pairs or something in that family, that I still have to do something that directs the mouth as to what to do." That's why a lot of people are looking at place-manner-voice, and because that's something physiological.

The other thing that I want to say about this is, the whole field was really focused on phonetic, the phonetic piece of the oral mechanism. Meaning, the articulation. The mouth is kind of the source of speech. We've focused on that until, and through the seventies. Okay, late seventies, the whole phonological, auditory, cognitive, language piece started coming in the late seventies. Eighties, it was big-time pushed, okay, and it has never swung back. That's one reason.

You look at myofunctional, and the whole concept of, "Ooh, it really focuses on the mouth and what's going on, and different things that can impede speech production," which I think is a really good thing. I think within that functional piece, we need to add some of those things. Yet, as a field, and as researchers, and professors, they don't look at it that way. They are training our new speech-language pathologists. Unless you go to, or you attend your podcast, or maybe something that I've done, or there's a lot of other people that are still trying to involve the mouth, unless you do that, you're not going to get that piece.

Especially, since 2007, 2008, there was such a brew haha of, "Don't touch the mouth. We don't want to do that." I'm like, "Huh? I'm a speech-language pathologist. Thank you. " Totally [inaudible 0:16:47]. That's my two cents, kind of just sort of touch upon it. I've really focused on the mouth to try and kind of counteract, but I'm not opposed to doing phonological therapy. Why would I be? If it works, then do it.

[0:17:04] MM: Right. I think that also goes down to one of the things that I've really come to learn as a clinician is that, not every patient in front of me is a myofunctional patient. But it's a tool for differential diagnosis. Do they need a phonological approach, or are they having a placement issue, or is there an overlap? Because that happens too. I just want to touch on something really quick, I think it was really interesting when we were talking about the functional versus organic, that that structural and sensory piece goes so much further beyond what we're currently looking at. Like structure can be more than cleft palate. Like you said, they were talking about malocclusion and speech production in the fifties. It's not anything new, but we know about it.

Then, just talking about that proprioceptive and tactile sensory awareness, we can pull that from our occupational therapy fields that we have those sensory systems and all other parts of our bodies. Why would that not also exist in our mouth? So yes, I just wanted to kind of touch on that, because I think that's really interesting. I graduated in 2020, and we looked at this, and we learned about it, but it kind of stumped me whenever we stopped at a very significant structural problem. We got a very basic oral mech exam, and you don't do anything. If they have a speech sound disorder, you just work on the sound. That's all. Just the sound. I had a hard time with that after graduating, it didn't make sense. That's kind of how I stumbled into myo. But yes, that was fabulous.

[0:18:36] CB: Yes. Well, we really need to focus on what's going on with the person. That's why I call my type of therapy, I guess, and I can probably do that, because I've been refining it over the past 30-plus years. I call it capability-based therapy. If you look at what capability means, you can have in capabilities, either in the mouth, or cognitive, or how the person is hearing it. So I want to address the capability of that individual, and enhance their capability, and then put it all together.

This whole piece of dividing up, either it's phonetic therapy, or phonological therapy, I think is unfortunate. Because you have this issue that we've sort of divided the baby. If you look at speech, and we've divided it based on articulation, and speech-sound therapy. So we've divided it. If I could interject, and say, "Hey, if I could just snap my fingers, and change that reference to either articulation or speech sound therapy, I would call it speech production disorders or speech production delay, or speech production therapy." Because I want to look at speech production, I want to look at the auditory piece, the cognitive piece, the oral, craniofacial oral respiratory piece, everything that goes into speech production. 

I think, if we kind of look at it from that perspective, it would open us up to really take a better look at what's going on with the individuals that we're working with. Right now, we're still just kind of categorized, and we like to do that, and it makes us feel good that, hey, we're just Ð the thing is Ð I have always taken exception to, "I'm going to make my therapy plan." Well, I need to know a variety of options, of therapy methods, and strategies, and so on. But I need to fit, what I know into what that individual needs. A lot of times, I remember I would Ð especially when I was a student, I would have my plan. Then, it didn't fit with what the kid wanted to do, or needed to do. I like to be armed and relatively dangerous, but I want to be armed with whatever that individual needs. I think that is being a quality therapy, and then be able to see, and then put it to use and application.

[0:21:26] MM: I love that. That's really what we should be like, I mean, that's also part of evidence-based care. Like the client's input and values, but I feel that also includes the client's needs, their deficits, what are they needing to improve, and are we able to individualize our treatment plan to those deficits. Because every person on your caseload is going to present differently.

[0:21:45] CB: They absolutely do. Yes, definitely.

[0:21:48] MM: Can you kind of talk about Ð is there ever an overlap between phonological and articulation disorders where a motor approach and linguistic approach are both needed?

[0:21:59] CB: Of course, and that's kind of where I was headed. Speech is a combination of many different things. I actually Ð there is a researcher back in my day, Marc Fey, Dr. Marc Fey, and he was actually from Canada, and then he ended up, I think at a University in Kansas somewhere. I always liked his research, and what he did, and why he did it, and it was more practical, and he looked at things pragmatically. I found an article, and it was a 1992 article. So about 31 years ago, that Dr. Fey wrote this. I want to read part of this, because I knew that you're going to ask me this.

There was a time when we were Ð as I said, focused on the oral sensory motor piece. Then, we just transitioned away from that into the purely phonological piece, purely the speech sound, and that was it, but there was a transition. That transition happened really in the eighties and early nineties. This was an article that was written by Dr. Fey in 1992. It's called Articulation and Phonology: Inextricable means, and I look this up. I want to know the exact definition. Impossible to disentangle or separate. I want to read this a little bit if that's okay.

[0:23:30] MM: Absolutely. He says, "For many speech-language pathologists, the application of the concepts of phonology to the assessment and treatment of phonologically disordered children has produced more confusion than clinical assistants." Now, that was in 1992. "At least part of this confusion seems to be due to the expectation that, since new terms are being used, new clinical techniques should differ radically from the old ones. The basic intent of this paper is to show that adopting a phonological approach to dealing with speech sound disorders, and that was a new one, does not necessitate a rejection of the well-established principles underlying traditional approaches to articulation disorders."

He says, "To the contrary, articulation must be recognized as a critical aspect of speech sound development under any theory." So, I'm going to say, in the early 90s, there were some researchers and professors that were trying to say to drag articulation along and say, "Don't forget the source of speech. Movement is the source of speech. The mouth is the source of speech. Let's not forget that." Yet, we did. We did. Right now, we're fully into phonological.

Then, you have the myofunctional people that are coming in and really legitimately saying, "Hey, here are some things that we can do legitimately from an oral perspective." Now, I'd like to kind of jump into those three things that I promised. I've got those three things, the essential components to speaking and swallowing, so I want to jump into that. Is that okay, Madi? 

[0:25:18] MM: I just have one question. You were kind of on this whole wave, and it seems Ðhave you heard of the whole language, versus the science of reading? It was like, I think in the seventies or eighties, there was this rise where they stopped teaching phonetics and just started to be like, "We just have to teach them to enjoy it."

[0:25:35] CB: I know. I was in the schools in whole language, and I can tell you all about whole language.

[0:25:41] MM: It almost seems like there's this overlap between switching, with whole language coming up, and then the same emphasis on phonology, and decrease of the speech sound kind of happening, all kind of jumbled together almost. I don't know, just very similar timelines hearing you break it down. I just thought that was kind of interesting.

[0:26:00] CB: Yes, it is. It is. It was unfortunate, because whole language did not work out. I mean, not at all. Thankfully, there's a swing back to looking at phonics and so on.

[0:26:10] MM: The thing with speech, we've had this swing back with myofunctional therapy and looking at the science behind, how do we make a sound. It's not just what it sounds like.

[0:26:19] CB: Yes. If you look at all the reading literature, it seems like, "Hey, maybe we should just land on something that works and stick there." I'm kind of there with speech. Let's just land on what works. Okay. But instead, again, it's kind of trendy. But yes, yes.

[0:26:37] MM: Sorry. I didn't mean to Ð

[0:26:39] CB: No, no.

[0:26:39] MM: Ð squirrel I just thought it was an interesting Ð

[0:26:41] CB: Yes, that's an interesting point, the whole language thing. I remember, and what happened was that there were whole language schools. There was no demarcation in rooms, everybody just kind of Ð we had a classroom over here, it was just big rooms. A classroom over here, and a classroom over there, and everybody was interacting, and whatever, and it was a mess. Kids needed specifics. They needed the phonics, and the phonetics, and so on. It kind of went through that, and it's unfortunate. There's a lot of people that just have difficulty reading today, because they went through the whole language piece. So yes, it's too bad, but I guess we learned what doesn't work. 

Okay. I'm going to jump into this. We have about a half hour here or less. I want to just talk specifics. If we had really addressed some of these things from my perspective, then, I don't know if we would be in this model. Because what I talk about has been around a long time. I talk about lateral bracing, the sides of the tongue bracing itself on the sides of the teeth for most of the sounds that we say. I'm still doing research and so on, and I'm doing some research right now because I'm doing a course at the end of December on sound stimulation. I found a book that I think it's a 1921 or 1929, where they were doing palatography, and they were talking about the sides of the tongue. They didn't use the term bracing, but just anchoring the insides of the top back teeth. Okay. That was a century ago, and you still don't hear about it.

There's other things here that I've kind of liked to bring up, but that's one of the biggies. The first thing that I really want to address here is that all movement, all movement comes from two concepts, two words, stabilization, and mobilization, everything. I don't care if you're dancing, I don't care if you're swishing down the ski slope, I don't care if you're writing. If you're speaking, if you're swallowing, you have to have points of stabilization in order to give the mobilization piece or pieces control. Bottom line.

[BREAK]

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[INTERVIEW RESUMED]

[0:29:38] CB: This principle has been around for a long time, and I got that basic principle from whole body movement books. They've been talking about it. If you look at the 2017 really good journal article by Gick, and I actually wrote a Therapy Matters blog on it, and I think it's number seven. He did, he wrote a very brief, but really good article called, Speaking Tongues Are Always Braced, which means, the tongue, the sides of the tongue are touching the insides of the top back teeth to one degree or another during speaking. I'm talking consonants, I'm talking high front vowels, and high back vowels, not low fronts and low backs. But high front, high back vowels. That lingual consonant, almost all of them have some level of lateral bracing, period. Well, wouldn't it be really good to add that, that piece too if you're talking about placement, hey, that would give them. Just stroke the sides of the tongue and the primer of the palate, and say, "Hey, get your tongue up there." Okay, if they can.

Now, there may be issues where they can't, and then that's kind of a nice thing for you to discover. Because then, there's other things that you can do prior to that to get the tongue up there. But just that piece of knowledge, I call it components of speech production. That is a really important component, is stabilization. Now, if what I just described is external stabilization, sides of the tongue, and the sides of the teeth to one degree or another. I put it that way, because if you're making an /n/, you're going to have full, surface-to-surface contact, sides of the tongue and sides of the teeth.

If you're making a /t/ or a /d/, you're going to have a little bit less. If you're making it /s/ and a /z/, a little bit less. /Sh/, you're going to have less, because you're going to have more the front part of the tongue lowering to allow more air to flow through, et cetera, et cetera. For /k/, /n/, /r/, you're going to have stabilization on the back corners of the tongue. While the mid portion of the tongue moves.

Another important point is, that you've got to have for speaking, and I'm going to get to swallowing here. But first, speaking, you've got to have stabilization, the points of stabilization, near the moving part, near the moving part. It's very much like writing. You had your pencil in hand, you're anchored on the table, and you write. So you have your stabilization mobilization. I am not stabilizing up here with my shoulder. I have stabilization near the moving part. The smaller the movement and speech is very small. Swallowing isn't. 

Swallowing, I kind of envision swallowing, you have your combat boots on and you're walking through tires. That's swallowing, it's bigger movements. Not speech, you're on ballet slippers. What is that when you're doing Ð you're towing, whatever. It's just this little, itty-bitty movements. They have to be because you got to fit them all in coarticulated speech, so you've got to have small movements. In order to do that, you've got to have good stabilization. Now, I'm talking about external stabilization. Okay, external stabilization. There's also internal stabilization. 

Just from a larger standpoint, think of a th, you have minimal external stabilization with a th. But have you ever tried to teach a floppy tongue to make a good th? It's not going to work. So th, you have to have good internal stabilization. It's just different. Now, also, you have refined internal stabilization of looking at your refinement is here in the middle of your tongue. When this part of your tongue tightens, that enables the front part of your tongue to move or to sustain in space, like for an s, or an sh. 

You have external stabilization, you have internal stabilization, which allows when you can track that mid-tongue. That is what gives you controlled front tongue vertical movements, your external and your internal. Got to have it. Got to have it. I mean, that stabilization piece is what gives you controlled mobilization. If we look at place-manner-voice, that just kind of, maybe it focuses with the front part of the tongue for an s, and we don't even think about what's going on with the rest of the tongue, which is unfortunate. Because there's a lot of things going on with the rest of the tongue that is enabling the front part to move and interact, or lower, and sustain itself in space while air is moving through.

Let me give you kind of an interesting little factor, or factoid, or something. All fricatives are spatial. Every single one of them requires the individual to set up in close proximity with an opposing articulator and hold that position while air moves. It's the exact opposite of plosives. You can move in a big way, /p/, /b/, /b/. But if I'm doing /s/, you can't really fudge on that. You can fudge if you're doing a /sh/, a frontal. But for fricatives, they're all spatial, you set up a space and you have to sustain that position while air courses through.

Now, how are you going to do that if you don't have stabilization? You want to do stabilization up the hill, externally and internally, and that's what gives you the capability to generate the mobility. Okay, got to have it. 

[0:36:23] MM: Can I ask you a question about a frontal, this patient I have? He has such great intrinsic and extrinsic motor function. For people listening, extrinsic is going to be how the tongue can move in and out of the mouth, side to side, those kind of more gross movements of the tongue. The intrinsic are, how can they shape the tongue. He has like a really good bowl, and a taco, and he can do a really great suction, and point his tongue, and hold it up off his teeth.

But then as soon as we go into speech for an s, we worked on t placement, and not stretchy t. He can do it and very structured, but it's tricky for him. But what I noticed today is he has this kind of fat tongue. It just kind of looks fat whenever it sneaks forward. That's that, him not having that stabilization from the intrinsic muscles if it's that kind of fat and just kind of sneaking forward? Is that kind of Ð

[0:37:14] CB: Where does he rest his tongue?

[0:37:15] MM: We're working on habituating rest posture, and it's up.

[0:37:19] CB: Good.

[0:37:19] MM: He's reporting good resting posture.

[0:37:22] CB: Yes. And you want to check that. Now, he's supported.

[0:37:27] MM: In the therapy room, he's showing good rest posture.

[0:37:30] CB: Good. Then outside?

[0:37:31] MM: Even reporting is good outside, and working on doing tongue checks with mom and things like that.

[0:37:36] CB: And doing what?

[0:37:38] MM: I call them tongue checks, where they say in the car something, and they might have them Ð see where the tongue is resting or check in with them, and see how they are. That's just the therapy name I use for them. 

[0:37:49] CB: Okay. All right. Good. Good. You use the extrinsic muscles, and the intrinsic muscles, and the extrinsic is really what's going to pull the whole tongue back and elevate. The next thing that I was going to actually talk about, this is a really good segue, and I'll address what you're saying here with this piece. That there is Ð because we just covered stabilization mobilization. I want to move into next, that the tongue has Ð and I need to talk about stabilization mobilization for swallowing, so don't let me get away without doing that.

The next one is that the tongue has an operating zone. There's an operating zone. It's up within the dental arch, is where most speech sounds are produced. I call that with my kids, that that's the speech neighborhood, because you can access /t/, /d/, /n/, /s/, /sh/, /j/, /n/, /y/, /k/, /n/, /r/. That's your speech neighborhood. Then, you can zip down here for your th, but your speech neighborhood is up within the dental arch. When you address that, and that really is an extrinsic thing, the whole thing has to Ð if the tongue is low and forward, it has to retract, not just the front, because that's what they want to do. But the whole thing needs to retract, and then needs to go up to solidify that new operating zone.

There's a lot of our kids, their tongue is in a lowered position or a low forward position. I see both of those things as being kind of separate. I mean, they overlap. It's kind of a Venn diagram, but you have down, which is kind of a gravity thing. Then you have down and forward. When I see the forward, I'm like, "Why are they doing that? Are there large tonsils in a small space, and they can't retract their tongue?" Because they kind of want to breathe and it might kind of cut off the breathing piece, and so their tongue is more forward. Or is their jaw lowered and it's kind of jumping forward? Why is all of that happening? 

I want to look at that operating zone. That to me is kind of what you're talking about to a degree. Also, to really get to that consistency of that operating zone, so that you can generate your external stabilization, and your internal stabilization, and interact with the alveolar ridge, and the hard palate, and zip back in with your soft palate area, the velum, and so on. You're in that zone, and so that you can do that. That is why we do, and this is the third thing, or that's why it's important to do the oral resting postures. Because it helps them to generate consistency of that operating zone, so that you can generate your stabilization and mobilization. It all works together. I mean, it's super important. I would really say, for your client, I would just make sure that zonal pieces is in there, and that their tongue is in the desired position for their oral structure.

[0:41:19] MM: I think you're absolutely right. I was talking to him today. And for some reason, I was so focused on, "Oh, what's the intrinsic muscle function? How is that doing that?" I didn't even listen to my client when I was, "Okay. Can you tell me what are you feeling the difference to be between whenever you produce your s between your teeth and whenever you have it behind your teeth? He goes, my tongue pulls back. He told me what we need to work on in my session today. I was just so caught up in what I thought was right, that I didn't take Ð

[0:41:46] CB: Good for him.

[0:41:47] MM: I know, he's a good, great kiddo.

[0:41:49] CB: Good for you. Yes, he's going to be a speech therapist when he grows up.

[0:41:52] MM: I'm telling you.

[0:41:53] CB: Yes, there you go. Yes.

[0:41:55] MM: But yes, that's excellent.

[0:41:56] CB: Well, this resting posture piece, a lot of people are, "Well, I don't know. I don't want to have to take time to do that." That is a huge piece of carryover. It's a huge piece of carryover. You can get somebody that can produce a good speech sound or sounds no matter what technique or methodology that you're using to get there. If it sounds good, but they don't have the stabilization mobilization that they need, okay. And because Ð and I get back to Gick's article, that speaking, that conversational speech, you always have that lateral bracing. It's there during most of our conversation. 

I'm looking at the stabilization mobilization of individual speech sounds, because that's what's needed during connected speech. If I don't address that, and if the person doesn't have this automaticity of the tongue going back. You talk, talk, talk, talk, talk, and then when you stop, it goes up there, your lips are closed, and all of that. And you go back to that position, and you're at the ready for the next round of speech. During their non-speaking time, if the tongue is down, and lips can be open, or lips can be closed, but your tongue can be down. Obviously, if the lips are open, the tongue is down. But if the lips are closed, tongue can be down as well.

Just because lips are closed, don't trust the tongue. You want to make sure that they're at the ready, they're in that optimum position for the stabilization, the optimum stabilization, and mobilization. That's what I call building the capability, and really taking a big, deep introspection into the components of speech production. Going beyond the sound of the sound. Now, some kids can get it. Here, say the sound, and they'll figure it out. Some kids get it after figuring it out for about two years. That's when the kid and a speech-language pathologist becomes very frustrated. 

But if I'm pointing these things out, and you said something really important about 10, 15 minutes ago, and I didn't stop you on it. But you were talking about the intraoral sensory piece. I'd really love for everyone to think of speech therapy as being a sensational task. Everything that we do to try and impact that person to produce that sound, because we're over here, they're over there. Everything that we do is sensation. "Here, honey, look at your mouth. Here, honey, look at my mouth. Look at the mouth model." Okay, that's all visual sensation.

Auditory, "Here, say the sound /r/, /r/" or "Say the sound /s/" or "Say the sound /f/." That's the auditory sensory piece. I'm big on adding to that, adding the tactile and the proprioceptive piece. The tactile being, "I'm going to get in there." Even with just a tongue depressor, and stroking the sides of the tongue, and the perimeter of that palate, and saying, "Here, put your tongue there." That's a tactile sensory indicator. All you're doing is adding to your sensory input in trying to impact the production of a speech sound or impact the swallowing. 

That just kind of opens up the therapy piece of, what form of sensory input can I do to try and impact this person? What form of auditory? Am I going to get on the floor, and I'm going to get right by their ear, and I'm going to say the sound? Or am I going to use some sort of an auditory device? I've done something called mind matching for years, where I have them close their eyes, and I'll say the sound or say with the sound of the initial position. I'll say, "I just want you to listen to it, and I want you to say that in your mind." So I have them do mind matching, and it's not all of it. But that auditory piece is very, very important. I will be the first person to say, "Don't ignore it." But I don't want to ignore the speech source, either. That sensory piece, it's all sensory Ð therapy is, pull out the stops, whatever you have to do to impact them to have a sense of what to do. Yes. So I would just want to add to that, that's all.

[0:47:23] MM: love it. Then, I think proprioception is really interesting and interoception. Also, how is your patient feeling that within their mouth, because I feel how my tongue feels and it touches against my alveolar ridge to make a t, d, or an n. I can feel my tongue bracing on the sides of my teeth for /ch/, inch. The patient also has to be aware of their own mouth doing that without additional tactile input as well. So it's just the whole Ð we're sensory creatures.

[0:47:55] CB: Yes, we are. Those articles I was talking about, the somatosensory piece, they talk about tactile and proprioception. From a speech-language pathologist standpoint, all I know to do, to heighten proprioception is have them close their eyes. I say, "Send a spy down to your mouth, or down to your tongue, whatever we're focused on, and focus and feel. Focus and feel. Focus and feel." And really focusing on the tactile piece, or the movement piece. When we get the sound, we get it. We have the stabilization mobilization. I like to first practice it by having them go from resting positions, into the speech sound, and then back.

[0:48:40] MM: Ooh, I love that.

[0:48:41] CB: Resting position, into the speech sound, and back. That is your first introduction to movement. Because we always go back, as I said, when you're done speaking, you go back to your resting position, and they do to sort of wait there, and idle. When the light changes, you step on the gas, and you move your mouth and off you go into speech, or whatever. 

[0:49:02] MM: That's also a perfect way to kind of go back and teach that external stabilization. Here is where you anchor, and different parts of your tongue you're going to move depending on your speech sound, but this is the general anchor, and this being the upper dental arch. So important.

[0:49:14] CB: It's super important. That's been around for decades and decades. The part about mid-tongue contraction has been around since 1986. I got that from the physiology literature. These things have been around, and everything that I do, pretty much almost everything that I do is in the literature somewhere, and I've just sort of pulled it together. 

I want to focus on swallowing as well. I love working with swallowing, because it's such a simple, simple Ð all it is, from my perspective is suction. So you have intraoral suction, intraoral suction that pulls the contents onto the tongue, either over the front part of the tongue or around the sides. So you suction, and then you have bite. And guess what that piece is?

[0:50:24] MM: Stabilization.

[0:50:26] CB: Stabilization. There you go. Good, good. So you stabilize, because your whole tongue is going up to the top, and you are squeezing, and lifting. So you're doing front, middle, back, sort of that rolling, stripping. So having teeth together gives you a solid footing. Somebody's holding the ladder for you. So the tongue has to go up to the top, and swallow, and down. So that tongue is moving vertically. Just like speech sounds, which I didn't mention, but all speech except for ths is vertical. All speech sounds are vertical. Front tongue vertical, and back tongue vertical. And you have mid-tongue vertical for the /y/. But speech is vertical. 

I can categorize sounds of front tongue sounds: /t/, /d/, /n/, /s/, /sh/, /ch/, and all of those. And back tongue sounds, /k/, /c/, /u/, /r/ as far as lingual. I can work on s, and I can work on sh, and I can work on /ch/ from the same perspective. Because all we're doing is we're just altering the stabilization and the mobilization just a bit. So, I love the way to categorize the speech, and then also the swallowing piece is just section bite, squeeze, lift. I mean, that's what it is. The difference comes when, "Oh, am I doing it with just saliva?" or "Am I doing it drinking continuously out of a cup, or whatever, or through a straw, or just taking a sip is different than continuous. Am I chewing something that's Ð or am I manipulating pudding, or am I chewing meat? Or do I have a cracker where I'm getting that little bits all over the place, so I have to really suction?"

I think the difference comes with the different types of inconsistencies and textures of your food and your liquid. Is it coming in from the outside or is it already in there? But it's all suction, bite, squeeze, lift. I have to be concerned about the direction of pressure rather than horizontal, and the tongue at the horizontal midline. I want the whole thing to go up and apply that pretty firm compression and rolling stripping motion on the top.

I've got to have good solid footing there. I'm going to say, there's fewer moving parts, and the parts are bigger than the speech. The speech is much more complex, and has more moving parts, and more options for stabilization mobilization. But I do resting postures for both, because your operating zone is up within that upper dental arch for both.

[0:53:21] MM: What are some ways that you target habituation of resting posture and checking to see if they're doing it during their sessions?

[0:53:30] CB: Well, I like to sneak into resting postures, and start off with just working with 10 seconds, and then pause, and then doing another 10 seconds, and then pause. I like to look at a short length of time with three reps, then incrementally over time, increasing that time. You can ask them where's your tongue, and say, "I want to see. Is it here?" If I say. "Where's your tongue?" And they go Ð take that split second, then you're going, "Oh, it wasn't there. Was it there? Really? Tell me the truth."

Also, on some individuals, you can see. Here's my tongue. It is down. I'm not pushing it down. Here's pushing. Here's just Ð

[0:54:27] MM: In terms of it though, that will just be listening to the audio. Char is showing how underneath her chin, it kind of bulges as the tongue is resting low. And then if she pushes, it bulges a little bit more. Then if she raises it, it is Ð

[0:54:40] CB: It goes away.

[0:54:41] MM: -gone. It's all smooth with no under-the-chin bulge.

[0:54:46] CB: Here, it's down, just resting down. So sometimes you can actually see it on individuals if their tongue is down. Not everybody, and especially with kids, because a lot of times, they're not still. But usually, I mean, you just Ð if they come in with lips that are parted, then you're going to have to work on the nasal breathing piece and making sure that there's not an obstruction there, that they can actually breathe comfortably and consistently there. 

That's kind of how I find out, but I like to do it incrementally over time. Because you're focusing on the position of things, and that's different than what they've been doing. But you're also focusing on the physiology of it. The muscles may get tired, and you're also focusing on the psychology, the psychological aspect, because I want their brain to say, "Yes, this is feeling good. I can do this." I sort of sneak up behind it, and take some time over time to incrementally lengthen the time. And I have a book on that. I love that one, yes. It's called The Key to Carry Over. It's focusing on resting postures, and it takes you through that process and so on. 

[0:56:12] MM: Another one for me to go Ð another one to add to the collection.

[0:56:17] CB: Well, whatever. Yes. Just so that everybody knows that yes, that there is something out there. I've written a lot of blogs on it. I think I did a three-part blog on my speechdynamics.com website, and I call it Therapy Matters. So you can go on there and look at their resting posture piece. There's a bunch of stuff on there.

[0:56:40] MM: Jonie had a question. Do you ever use rubber mouth puppets when you show what the tongue should do? r

[0:56:46] CB: Rubber mouth puppets?

[0:56:48] MM: Mm-hmm.

[0:56:48] CB: The one that I like is this. You can use any of them that you like, but I like this one.

[0:56:56] MM: Char is showing a giant, hard-mouth model that has the hinges for the back.

[0:57:03] CB: Yes. And the individual, this person that you're working with, you can put your hand in here, and show, "Hey, here's your tongue now. Ooh, look, it needs to go up in here. Put it up in here. So you show how the front fourth to third of the surface of the tongue is on the alveolar ridge, and the size of the tongue. Then they can put their hand tongue in there as well. 

But any, any visual that you have, that would be a visual. This one, you could add that proprioceptive piece and tactile piece with their own hand. Sometimes, just that piece is like, "Oh. Okay, yes." Then, they can replicate that better in their own mouth.

[0:57:46] MM: How awesome to tie in, so you could like give them the tactile input on the hand up in the mouth model. Then, you could immediately say, "Okay. This part on your hand is this part on your tongue." You can like make that direct, "I can see what's on my hand. I can feel it's on my hand. Let me tie this into Ð" it's a little tricky to see your own tongue. So I love that to kind of pair that whole body to the mouth, and just like provide that extra layer.

[0:58:13] CB: Exactly. Exactly.

[0:58:14] MM: That's awesome. 

[0:58:14] CB: Yes. Yes. Again, any form of sensory input that you can do, the little rubber, the rubber model. I used to use those. I know that there's different sizes of those, and all of that. We used to carry those. Speech Dynamics used to carry products. I've used them. This type, and it's called the Ajax mouth model. It used to be on Amazon. I haven't checked recently, maybe it's back.

[0:58:43] MM: We'll check it out.

[0:58:43] CB: But it's Ajax mouth model, A-J-A-X. It's in another website, and I forget what that website is. It used to be really reasonably priced.

[0:58:56] MM: Let's see. I will share the Amazon link. It is currently unavailable on Amazon, but let me see if there's other Ð

[0:59:03] CB: We just Google Ajax mouth model.

[0:59:06] MM: Ajaxscientific.com. 

[0:59:09] CB: There you go. That's it. That's it. It's the one that comes with the green big toothbrush.

[0:59:14] MM: I use this all the time in my practice. We even have tape on the back lateral, on the upper molars so we can show them like, "This is where we brace our tongue." We use it for showing them, like the alveolar ridge.

[0:59:27] CB: I love it. I love it. Yes.

[0:59:28] MM: Also really great for feeding therapy, letting your picky eaters crunch up food in between it. That's been a big hit.

[0:59:37] CB: Yes. Good. I love it. Yes, good, good.

[0:59:41] MM: Then Jonie, "I do use the rubber mouth puppet in my clinic along with the Ajax model. I like to use it for showing the tongue tip and where it goes. Sometimes I'll try to manipulate the sides of the tongue to show them, 'This is what the tongue is going to look like.' But it can get a little tricky sometimes with that rubber tongue. Ours is a little small."

[0:59:57] CB: Yes, whatever works. Whatever works.

[1:00:02] MM: Whatever you have in your clinic. 

[1:00:02] CB: Yes. Yes. Exactly. Exactly. So yes. Good. Good. Thank you. Any other questions, comments at all? We had from Laurie, "And a new version of whole language is going around again in schools with adverse impact, especially after the pandemic." Oh, I didn't know that, that it was back.

[1:00:23] MM: I know, I hate that.

[1:00:23] CB: Who put it back? We had the language piece, but Ð

[1:00:31] MM: Do you think there was any Ð

[1:00:32] CB: Any questions?

[1:00:32] MM: I have one. Do you think that there was Ð being in the whole wave of all of it, do you think there was any overlap in the rise of the whole language, and the phonological approach? Or was that just me picking at straws?

[1:00:43] CB: Maybe it was, because the whole language got away from the phonics piece. I don't know. I don't know. The phonology has taken hold, and I've read some really successful research articles. But most of the time, they're younger children. I think it's that, doing phonological approaches with the young kids is just really excellent. Coupled with the whole idea of, "Here's your mouth, honey." I know that that's been frowned on and whatever. 

But if you think about it, if you're teaching a child to color or whatever, they can see their hand, they can immediately see the result, but you can't see your mouth. You cannot see your mouth. The only way is to put a mirror in front of you. So you're totally just Ð at any given moment in time, you are relegated to tactile proprioceptive input with your mouth. There's a lot of young ones, that have no clue, that there's anything other than just the head. We want to differentiate and say, "Hey, you got a mouth, and you got some other mouth parts in there." I think, just looking at that whole sensory input with smaller children, and then coupling that with the phonological piece. I think that's just a really ideal thing to do. 

[1:02:13] MM: Absolutely. I 100% agree, Char. It's the way to go. 

[1:02:18] CB: Yes. Good.

[1:02:19] MM: Well, I don't think we had any more questions come in. But I thank you so much for your time this evening for coming on the podcast. I learned so much from you this evening. You gave me a lot of good ideas for therapy. Laurie said, "Thank you for the reminder of what I practice for 30 years. You tied it together amazingly."

[1:02:40] CB: Hi, Laurie.

[1:02:42] MM: I haven't practiced for quite that long, but I agree. I know that this is going to be an even better place to launch me forward in my career.

[1:02:48] CB: Good, good. Well, great. Well, it's been my pleasure, and it's just totally fun to talk with you, and share information. This is as we were just saying before, this is probably just our favorite topic. Crazy, isn't it?

[1:03:02] MM: For sure. 

[1:03:02] CB: Yes. Yes.

[1:03:03] MM: My absolute favorite.

[1:03:05] CB: Yes. It is. It is. Totally.

[1:03:07] MM: Thank you and I look forward to seeing you again.

[1:03:11] CB: Thank you, everybody. Bye-bye.

[END OF INTERVIEW]

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SLPL S11E8		Transcript

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