THE ORAL MOTOR DEBATE – PART III

Evidence-Based Systematic Reviews (EBSRs)

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In 2005, ASHA’s N-CEP surveyed ASHA members via the “Knowledge-Attitudes-Practices Survey” to determine what SLPs needed to effectively progress toward EBP. The N-CEP found the following:

Survey respondents remarked that they had little or no time to search and analyze the peer-reviewed literature. Further, the majority of clinicians reported that the evidence for effective clinical practice was nonexistent, conflicting, or irrelevant and ultimately identified a number of clinical areas in need of further examination (Frymark, Schooling, Mullen, Wheeler-Hegland, Ashford, McCabe, Musson, & Hammond, 2009, p. 175).

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EBSRs seemed to be one answer to these problems as they are compilations and discussions of best-available empirical evidence pertaining to clinical questions. They are meant to help practicing SLPs evaluate data in a streamlined fashion, so that the most effective methods may be chosen and incorporated into clinical practice. Justice and Fey (2004) recommended EBSRs of published research as a first step in helping SLPs find the “best current evidence.”

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EBSRs are qualitatively different from typical reviews of the literature found in most journal articles. They are a 17-step process (Mullen, 2006) involving the “critical appraisal of study quality,” “identification of study by phase/stage of clinical research,” and “synthesis of the body of evidence by quality and stage of research” (Frymark, et al., 2009, p. 177). However, the “level of evidence” under which EBSRs fall (See Table 1) is a question for ASHA’s N-CEP.

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In 2009 and 2010, ASHA’s N-CEP completed seven EBSRs on nonspeech and behavioral/nonfeeding/nonswallowing oral sensory-motor treatments. With so much discussion surrounding the topic of oral exercise, these EBSRs (summarized in Appendix A) seemed to be a logical “starting point” for ASHA’s N-CEP. However, six of these EBSRs addressed feeding and swallowing, while only one addressed the use of nonspeech oral exercise in speech treatment (the apparent topic of the “oral motor treatment” controversy). The single EBSR on nonspeech oral exercise revealed “insufficient evidence to support or refute the use of OMEs [oral motor exercises] to produce effects on speech…in the research literature” (McCauley, Strand, Lof, Schooling, & Frymark; November 2009, p. 343), confirming SLPs’ observations that empirical research frequently identified areas for further study rather than “evidence for effective clinical practice” (Frymark, et al., 2009, p. 175).

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While the EBSRs on oral sensory-motor treatment were a good “starting point” for ASHA’s N-CEP, EBSRs, meta-analyses, and empirical studies of the many forms of pediatric speech treatment are greatly needed. According to the United States Department of Labor, approximately 48 percent of SLPs worked in educational settings in 2010. ASHA’s 2010 Schools Survey – SLP Caseload Characteristics Report revealed that 91.6 percent of school-based SLPs treated articulation/phonological disorders and 58.8 percent addressed childhood apraxia of speech (CAS), while only 9.4 percent treated feeding and swallowing disorders. ASHA’s 2009 “Health Care Survey” revealed that SLPs in healthcare spent a greater portion of their time (i.e., 24 percent) treating articulation and phonological disorders than pediatric feeding and swallowing (i.e., 16 percent). In light of the large percentages of SLPs treating pediatric speech disorders, it is essential the empirical research be conducted on specific speech treatments (e.g., “bottom-up,” “hierarchical,” “auditory-visual,” “tactile-proprioceptive,” etc.) and populations (e.g., CAS, childhood dysarthria, articulation disorders, phonological disorders, etc.).

Opinion vs. Empirical Research

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In contrast to the single EBSR on the use of oral exercise in speech treatment (McCauley, et al., 2009), most other recent articles on this topic have been theoretical in nature (expressing the ideas and opinions of the authors). These articles stressed the importance of empirical research, yet many of the authors had not done empirical studies on the topic. Therefore, no new empirical data was provided for SLPs’ clinical decision-making.

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In 2008, a total of 14 theoretical articles were published on the topic of nonspeech oral sensory-motor treatment. The five-article “Clinical Forum” series (found in LSHSS)9 was discussed in Part II (Bahr, 2011b). Another nine theoretical articles appeared in Seminars in Speech and Language (Volume 29, Number 4). A tenth article in this series was a research article (Forrest & Iuzzini, 2008). The nine theoretical articles in Seminars in Speech and Language (Volume 29, Number 4) added to the SLP knowledge base because authors from different areas of the field discussed a variety of treatment populations relative to the topic (summarized in Appendix B). Despite the usefulness of theoretical journal articles, empirical research is greatly needed.

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Most of the theoretical articles on the topic of nonspeech oral sensory-motor treatment were informational. However, three authors (Lass & Pannbacker, 2008; Kamhi, 2008) expressed strong opinions regarding nonspeech oral sensory-motor treatments and the SLPs perceived as promoting them. For example, Kamhi (2008, p. 337) stated:

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As I found more and more reasons to explain the use of NSOMEs [nonspeech oral motor exercises], I began to think that the more interesting question was to determine why a clinician is not using NSOMEs. The small percentage of clinicians (< 15%) who do not use NSOMEs [10] must strongly believe that these activities have absolutely no value for speech sound production. Someone needs to sample these clinicians to find out how they have been able to resist the allure of NSOMEs. The next step would be to recruit these “NSOME-resisters” to spearhead a practitioner-directed attack against the use of NSOMEs to treat children with speech sound disorders. I hope that the guest editor of this issue [Gregory L. Lof, PhD] will continue to lead us in the ongoing battle to reduce the widespread and indiscriminate use of NSOMEs.

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According to Kamhi (2008), G. Lof appeared to be waging a war. Similar yearly ASHA convention presentations and handouts by Lof and others (e.g., Lof & Watson, 2005; Lof, 2006, 2007, 2008a, & 2009) may have perpetuated this idea. Pannbacker and Lass (who were also openly opposed to the use of nonspeech activities and exercises) presented frequently at ASHA conventions (Pannbacker & Lass, 2002, 2003, & 2004; Lass, Pannbacker, Carroll, & Fox, 2006). Rather than a debate (where both sides were equally represented), there seemed to be a campaign against those who used the term “oral motor treatment” to describe their work.

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As examples, Lass and Pannbacker (2008, p. 415) and Kamhi (2008, p. 336) expressed a number of written claims, concerns, and opinions regarding SLPs they appeared to perceive as promoting the indiscriminate use of nonspeech oral sensory-motor treatment. They included the Oral Motor Institute (OMI) study group in their claims. Table 2 compares some of these claims, concerns, and opinions relative to information found contrary to them.

Kamhi (2008) and Lass and Pannbacker (2008) made strong statements and claims regarding the OMI study group, continuing education, and SLPs they perceived as supporting nonspeech oral sensory-motor treatment. However, independent study groups like the OMI are usually considered an asset in a field of study. They tend to bring fresh perspectives and “clinical expertise” (an aspect of EBP) to the topics under discussion. It would be difficult to find a study group, a professional journal group, or an organization (e.g., ASHA) in which the members do not have some vested interest. Such interests are disclosed as part of advertising and publication.

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Two statements from ASHA’s Code of Ethics (2010) have been points of interest throughout the three-part “Oral Motor Debate” series. The claims, concerns, and opinions listed in Table 2 (Kamhi, 2008; Lass & Pannbacker, 2008) should be considered in light of these statements.

ASHA’s Code of Ethics (2010, p. 4) states, “Individuals’ statements to colleagues about professional services, research results, and products shall adhere to prevailing professional standards and shall contain no misrepresentations.” The concerns expressed by Kamhi (2008) and Lass and Pannbacker (2008) regarding continuing education and the OMI seemed mostly unfounded and inaccurate (See Table 2). However, they may help explain some of the concerns expressed by SLPs in Part I of this article series (Bahr, 2011a) and the perception that academics and clinicians were on opposite sides of the controversy (discussed in Part II; Bahr, 2011b).

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Additionally, ASHA’s Code of Ethics (2010b, p. 4) states, “Individuals shall uphold the dignity and autonomy of the professions, maintain harmonious interprofessional and intraprofessional relationships, and accept the professions’ self-imposed standards.” The use of words such as “attack” and “battle” in professional journal literature (Kamhi, 2008, p. 337) does not promote this goal. The SLP profession would be better served by cooperative and collaborative professional efforts that focus on improving SLP research, training, assessment, and treatment.

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In a 2008(b) ASHA convention poster session, Bahr asked some questions in response to the concerns and claims expressed by Kamhi, Lass, Pannbacker, and others:

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• “Are continuing education courses really promoting nonspeech treatments in place of speech treatment …?”

• “Do SLPs trained, certified, and licensed according to ASHA standards really provide therapy consisting largely or exclusively of nonspeech or nonfeeding work with the expectation of improvement in speech or feeding?”

• “Would a properly trained SLP [speech-language pathologist] do oral awareness/discrimination and oral activities/exercises with children who do not need them …? If so, are these therapists properly trained?”

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Three questions were then queried in the simple one-page “Survey for Future Research” (Appendix C) developed by Bahr (2008b):

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• “What is being taught at the undergraduate and graduate levels on feeding, motor speech, and mouth function? Are students still being taught how to adequately conduct, interpret, and use the results of an oral examination?”

• “How can continuing education better meet the needs of working therapists? Is there a way to better coordinate undergraduate, graduate, and continuing education on the topic of oral motor assessment and treatment as well as other topics?”

• “Is there a professional interest in an updated text on oral motor assessment and treatment? Should researchers and practicing clinicians collaborate on this?”

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These and other questions from “Survey for Future Research” (Appendix C; Bahr 2008b) targeted ideas for the resolution of the “oral motor treatment” debate. The results and discussion of this survey follow.

RESULTS AND DISCUSSION

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“Survey for Future Research” Summary of Results

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Three-hundred fifty-three SLPs from across the USA, including Puerto Rico, completed the “Survey for Future Research” (Appendix C; Bahr 2008b). This survey explored resolutions for the “oral motor treatment” controversy by asking respondents to identify questions they would like addressed on the topic. The questions seemed pertinent to the surveyed SLPs, as 60 percent or more responded to each question. Those completing the survey appeared to have an interest in the topic, as they either attended an ASHA convention presentation or participated in a website on the topic. Refer to Part I (Bahr, 2011a) for demographics and specific administration procedures for this survey. Table 3 summarizes the results of the “Survey for Future Research.”

Questions 1 and 6 from the “Survey for Future Research” were discussed in Part II (Bahr, 2011b). Regarding “Question 1,” 92 percent of the respondents were interested in a “clear definition of oral motor function and the many aspects of oral motor treatment (i.e., feeding/oral phase swallowing, motor speech, orofacial myology, oral awareness/discrimination, and oral activities/exercises)” to “help researchers and clinicians use this terminology more accurately.” Regarding “Question 6,” 79 percent of the surveyed SLPs were concerned about the appropriate place for and “use of nonspeech and/or nonfeeding oral sensory-motor treatments with appropriate populations.”

“Question 7” yielded 173 written comments and questions covered in the next section. Questions 2 through 5 queried oral sensory-motor research and training needs/ideas discussed in subsequent sections of this article.

 

 

Question 7: Written Comments and Questions

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One-hundred seventy-three additional written comments or questions were submitted in response to “Question 7” of the “Survey for Future Research” (found in Appendix C). It asked, “What other related questions do you have?” SLPs seemed to have much to ask or say on the subject of oral sensory-motor treatment.

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The largest percentage of questions and comments (i.e., 23 percent) involved evidence and research. Respondents were clear in their desire for more quality research to obtain definitive answers. More than one respondent pointed out the need for researchers and academics to work with clinicians to find answers. Respondents also wanted SLPs with clinical experience to work with researchers on developing evidence-based assessments to determine treatment effectiveness. Some SLPs expressed concerns regarding the current state of SLP research.

They suggested that:

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• researchers and academics were too far-removed from the types of problems clinicians face,

• academics and researchers were not researching clinically necessary and appropriate topics and populations, and

• treatments and techniques (with “larger” evidence bases) may reflect past or present topics of interest within the academic community instead of current consumer needs.

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Education and training questions/comments comprised the next largest area of concern (i.e., 14 percent). Surveyed SLPs expressed that graduate school should adequately prepare students for the types of clients and patients they will treat once they are working. A number of respondents seemed concerned that they did not receive training on specific oral sensory-motor topics such as swallowing and feeding in their university programs; yet, ASHA and employers expected them to perform these types of treatment. Several respondents questioned the wisdom of expecting SLPs to address such critical needs as swallowing without specialty certification. Many surveyed SLPs expressed the desire for a variety of good-quality workshops to address oral sensory-motor function, feeding, and swallowing assessment/treatment, since they had not learned about these areas at their universities.

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Thirteen percent of respondent comments and questions involved the impact of oral sensory-motor issues on speech and communication. Surveyed SLPs had many questions about treating clients and patients who exhibited significant speech concerns such as childhood apraxia of speech (CAS), childhood dysarthria, and other speech disorders beyond articulation and phonological concerns. Treatment for CAS appeared to be a particular area of concern for many clinicians. The PROMPT17 method (one reported treatment for CAS) generated a lot of confusion. Respondents wondered whether to consider PROMPT an oral sensory-motor treatment or not. They also wondered whether PROMPT was supported by empirical research.

Respondents commented on earlier developing skills that preceded speech development, including feeding and non-speech activities such as mouthing objects and other forms of mouth play. In light of the many developmental approaches to therapy, surveyed SLPs wondered why opponents of oral sensory-motor treatment did not value working on such earlier-developing skills. Some respondents expressed concerns that researchers and academics might be “missing the mark” by not addressing the underpinnings of speech problems.

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Twelve percent of respondents’ questions and concerns revolved around the oral sensory-motor treatment controversy and disagreement itself. Although one respondent questioned the need for agreement on the topic, the majority expressed discomfort regarding the conflict among members in the field. Some respondents expressed distress over the perception that others, within the field, seemed to be dictating therapy practices by asking SLPs to stop using techniques they found clinically successful. Most respondents expressed a desire for consensus that clinicians could use any method that they find works, without fear of censure by peers. While a couple of respondents indicated their disapproval of oral motor practitioners, more of the surveyed SLPs seemed annoyed with what they described as arrogance and a lack of open-mindedness in their peers. A number of comments indicated that SLPs would like ASHA to thoroughly research the topic and issue an official stand.

Eight percent of respondents had other treatment questions/comments, and another eight percent were concerned about the involvement of other disciplines. There were a number of questions aimed at the meaning of the term “evidence-based.” Some respondents interpreted it to mean solely founded in statistical evidence, while others found importance in anecdotal evidence. One respondent asked if anecdotal evidence in the “real world ever trumps the results of studies contrived in the laboratory.”

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Misunderstanding appeared to abound within the questions and comments gathered from SLPs. Case in point, one participant said that she thought universities did not teach students to conduct, interpret, and use the results of an oral mechanism examination [a long-accepted and basic aspect of speech and swallowing assessment] because “it is not evidence-based.”

Survey respondents also expressed interest in evidence and research by adjunct disciplines such as occupational therapy, physical therapy, orofacial myology, neurology, sports medicine, etc. A few respondents seemed concerned that other disciplines were “taking on” traditional SLP treatment roles while SLPs were arguing over “oral motor treatment.”

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Six percent of respondents’ comments and questions involved definition and terminology. Surveyed SLPs requested a variety of information. Some asked for precise definitions18 of treatments to dispel confusion over therapy practices. A number indicated the importance of clarifying the types of oral sensory-motor treatment appropriate for particular populations and problems. Respondents seemed concerned that misunderstandings within the field may be the result of researchers, academics, and clinicians who are not discussing like practices nor precisely specifying the populations under discussion. Some respondents indicated a desire for more information on the definition and etiology of motor disturbances, while one respondent expressed a concern about how to measure successful oral sensory-motor treatment outcomes.

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Another area of concern for respondents was the potential for “vested interest” in those SLPs who promote forms of oral sensory-motor treatment and sell products or services related to their practices. Survey takers expressed a desire for evidence from those without anything monetary to gain. This could be accomplished if researchers and the developers of products and services worked together.

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The number of written questions and comments in response to the “Survey for Future Research” (Appendix C) indicated that the topic of oral sensory-motor assessment and treatment is important to clinicians. SLPs are still looking for answers, despite hearing generalities that “oral motor treatment” does not work. This fact, in itself, highlights the importance of the subject and the need for more than basic speech therapy techniques to address the complex cases SLPs treat in schools, hospitals, and clinics. Clearly, there is also a need for objective data to support or refute specific oral sensory-motor practices used in speech and feeding treatment. The data from “Question 7” can be found in Table 4.

Question 2: Attaining the Empirical Evidence-Base

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“Question 2” from the “Survey for Future Research” (Appendix C) asked SLPs about the importance of clinicians and researchers working together on research projects. It read, “How can SLPs become more cohesive as a profession? Could group-design research projects combining the efforts of researchers (often doctoral level SLPs) with SLPs who carry active caseloads (often master’s level SLPs) be developed?”

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Sixty percent of surveyed SLPs circled “Question 2” as important, and an additional 40 written questions and comments were submitted on the topic (See Tables 3 and 4). The lower response percentage for this question compared to other survey questions may reflect SLPs’ lack of confidence in clinicians and academics working together to resolve the problem (the essence of “Question 2”). However, the large number of questions and comments (almost double compared to other areas) revealed the importance of solving it.

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The topics of empirical research and peer-reviewed journal literature were frequently discussed throughout the “oral motor treatment” controversy. Paucity of empirical research is not specific to oral sensory-motor treatment, despite the number of theoretical articles calling for research on the topic (See previous section “Opinion vs. Empirical Research”). Justice, Nye, Schwarz, McGinty, and Rivera (2008) reported limited group-design treatment research across SLP treatment areas when they reviewed the three major ASHA journals (i.e., AJSLP19, LSHSS, and JSLHR20) between 1997 and 2006. Paucity of peer-reviewed journal literature is also not specific to oral sensory-motor treatment. In a survey of 117 AJSLP articles between 2004 and 2007, Bahr (2008a) found limited peer-reviewed journal literature on most speech-related topics (i.e., motor speech, phonology, fluency, and voice). At the time, the majority of AJSLP articles focused on language and communication. The SLP field is in great need of treatment-oriented, empirical evidence and peer-reviewed journal literature across treatment areas.

In response to concerns within the SLP community regarding the generation of empirical research, Scaler Scott, Bahr, and Reardon-Reeves presented a collaborative research model at the 2009 ASHA Convention. The model supported ASHA’s “Strategic Pathway to Excellence” (ASHA, n.d.-a) by suggesting the active participation of ASHA members (clinicians and researchers) in the generation of empirical research and the use of this evidence in clinical decision-making. Scaler Scott, Bahr, and Reardon-Reeves outlined a systematic plan to unite researchers (who comprise approximately 1 percent of ASHA’s membership) and clinicians (who comprise approximately 81 percent of ASHA’s membership) on crucial research projects (statistics from ASHA, Year-End 2006). Roadblocks that could preclude the success of this plan were also evaluated and discussed.

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Figure 1 summarizes the research model suggested by Scaler Scott, Bahr, and Reardon-Reeves (2009). The first step in this model is to systematically match strengths, background, training, interests, and goals of academics and clinicians to create a research dyad. The clinician researcher provides the clinical caseload, teaches the academic researcher about the techniques/clinical procedures being studied, assesses and treats clients/patients, and takes data. The academic researcher mentors the clinician researcher as they set up the project, analyze the data, and write the resulting paper together.21 The academic researcher trains the clinician researcher to follow research protocol and assist with reliability checks. Proactive partnership, training, and coordination assist the dyad in working though individual and institutional roadblocks (e.g., knowledge gap, project time, funding, etc.). With a plan in place, crucial assessment/treatment research and improved relationships between academics and clinicians could result. Since clinicians tend to treat caseloads of individuals with similar problems, group-design research would be more likely to occur with this model, resolving the paucity of group-design research discussed by Justice, et al. (2008). Such research would provide empirical evidence for SLP clinical decision-making while meeting the needs of current clinical populations.

Justice and Fey discussed the progression from empirical research to clinical practice (2004, pp. 7-8):

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First comes the scaling up of research, or endorsing researchers’ conduct and publication of research that targets real clinical problems and, ultimately, is implemented in non-laboratory, clinical settings. Second comes the scaling up of practices, or removing barriers that affect the translation of research findings to clinical practices…. EBP requires a synergy between the research community, which is charged with accumulating evidence, and the clinical community, which is charged with examining the preponderance of evidence, to make decisions about the best ways to evaluate and treat children…. Systemic changes are needed first at the organizational level, encompassing the discipline and its professional associations, and secondly, at the individual level.”

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Empirical research in the SLP field is usually based on clinical problems. Such research has the potential to validate or invalidate clinical procedures which ultimately impact client and patient outcomes/welfare. EBSRs (such as those summarized in Appendix A) may be a “first step” in resolving the apparent “disconnect” between empirical research and practice. A collaborative research model may be the next step, and a revised training model may help SLPs put empirical research into practice.

Questions 3, 4, and 5: Training Needs/Ideas

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Three questions from the “Survey for Future Research” targeted SLP training needs/ideas relative the resolution of the “oral motor treatment” controversy (Bahr, 2008b; Appendix C). The response percentages were similar for all three questions. In response to “Question 3,” 78 percent of surveyed SLPs said they were interested in knowing what was “being taught at the undergraduate and graduate levels on feeding, motor speech, and mouth function” and whether students were being taught to “conduct, interpret, and use” results from oral mechanism exams. In response to “Question 4,” 75 percent of surveyed SLPs seemed concerned about ways continuing education could “better meet the needs” of working SLPs and whether there was a way to “coordinate undergraduate, graduate, and continuing education training.” In response to “Question 5,” 77 percent of surveyed SLPs indicated an interest in an updated textbook22 on oral sensory-motor assessment and treatment using a researcher-clinician collaborative model.

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The survey results revealed that SLPs were concerned about SLP training in the areas of feeding, motor speech, and mouth function. Additional written questions and comments (See previous “Question 7” summary) indicated that SLPs were concerned about their ability to meet current consumer23 needs with their present training. Therefore, a different training model may better meet the needs of SLPs and SLP consumers as well as the standards of EBP. Two questions would be important for this process:

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• What model could accomplish the coordination of training levels and programs from undergraduate through continuing education?

• What curriculum content flow could adequately train SLPs in the various aspects of oral sensory-motor treatment (e.g., feeding, swallowing, motor speech, and orofacial myology)?

Figure 2 is a conceptual model for evidence-based training that could be applied across the SLP field. In this model, “clinical expertise, best current evidence, and patient/client values” are inherent in all training levels (undergraduate training through continuing education). Textbooks, tutorials, assessment materials, and treatment materials (used as part of the training process) also reflect these three aspects of EBP. The arrows pointing from the tutorials, textbooks, and materials toward the various levels of SLP instruction demonstrate this concept. A training model, such as this, could help resolve many of the problems encountered in the “oral motor treatment” controversy (e.g., development of evidence-based assessment and treatment materials, updated SLP training on current treatments and populations, etc.).

Currently, the SLP field seems to be at least partially meeting the requirements of this evidence-based training model. Textbooks and tutorials are developed from relevant literature review and the clinical expertise of the author(s).24 Assessment materials are based on developmental and other norms, as well as client/patient behavioral observations. Treatment materials usually contain suggested activities that SLPs have found successful and motivational in treatment. They are not prescriptive in nature, and clinicians use their expertise to choose appropriate treatment materials for clients and patients based on assessment results. Yet, the paucity of empirical research has significantly limited the availability of “best current evidence” for these processes. In fact, few recent assessment and treatment materials seem to reflect all three aspects of EBP including the supportive empirical research.25

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With regard to SLP training, undergraduate and graduate programs adhere to ASHA’s standards and requirements. ASHA provides limited curriculum guidelines26 and significant academic freedom. University training programs often vary relative to available faculty. The clinical or research interests and expertise of faculty may determine specific courses taught, how they are taught, and some clinical aspects of training programs (e.g., types of clients drawn to graduate clinics or placements for student clinicians). Therefore, students may not receive instruction or “hands-on” experience with the variety of clients/patients/consumers treated in clinics, schools, and hospital settings. This may ultimately limit their ability to make appropriate clinical decisions in the work environment.

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Currently, continuing education (CE) is mostly consumer-driven. It is based on SLPs’, clients’, and patients’ needs and usually focuses on clinical decision-making. SLPs frequently take courses that apply to their current clients/patients and available jobs within the field. CE courses often attempt to provide training that SLPs did not receive at the university level. ASHA and its Special Interest Groups (SIGs) provide CE opportunities. ASHA also has many affiliated CE Providers who agree to detailed standards for course development and administration. Both academics and experienced master clinicians teach CE courses.

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The coordination of university training programs and CE could systematize SLP training. Such coordination would require that instructors have at least 5 to 10 years of clinical experience in the subjects they teach and an understanding of current empirical research. Students would then learn from experienced clinicians who could guide them to the “best current evidence” and teach them about the assessment and treatment of current clinical populations (e.g., children with autism, Down syndrome, CAS, dysarthria, orofacial myofunctional disorders, etc.).

Standardization of core curriculum at the graduate and undergraduate levels would allow CE to focus on advanced level, specialized training. A survey of what is currently taught in undergraduate, graduate, and continuing education programs would likely be the first step in studying the overall training process. A network of academics and clinicians who teach on similar topics could then be established, and “collective knowledge” could be used “to advance the goals” of the field (Rao, March 2011, p. 23).27 Team teaching (i.e., academics and master clinicians teaching together) could be effective at all training levels.

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SLPs want and need specific and appropriate training to assess and treat clients with oral sensory-motor disorders that impact the functional processes of eating, drinking, and speaking. The idea of incorporating oral-sensory motor training into university programs is not new. Pierce and Taylor (2001) surveyed 128 SLPs, and 97 percent of their respondents “believed that more coursework on oral myofunctional disorders [was] needed in [university] training programs” (p. 27). They suggested that “speech pathologists, orofacial myologists, ASHA, IAOM [International Association of Orofacial Myology], colleges, and universities work together to improve undergraduate and graduate training programs so that practicing clinicians are adequately trained to provide assessment and treatment of orofacial myofunctional disorders” (p. 30).

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In some South American countries, dentists and SLPs train together in university courses.28 SLPs, dentists, orthodontists, and others also train together in continuing education programs offered by the IAOM throughout the world. Interdisciplinary training with dentists and orthodontists likely provides SLPs with a better understanding of orofacial development, overall oral sensory-motor function, and the ways orofacial myofunctional phenomena can affect speech development and production. ASHA also has three SIGs that address the various aspects of oral sensory-motor function (i.e., SIG 2: Neurophysiology and Neurogenic Speech and Language Disorders; SIG 5: Speech Science and Orofacial Disorders; and SIG 13: Swallowing and Swallowing Disorders).

Table 5 represents one potential curriculum content flow from undergraduate training through CE for the topic of oral sensory-motor assessment and treatment. In this model, functional anatomy and physiology courses, taught at the undergraduate level, would be directly applicable to assessment and treatment. A course on typical sensory-motor development would provide information on detailed whole-body movement development (beginning at birth) that leads to task-specific processes (e.g., speech acquisition). A survey course on feeding, swallowing, orofacial myofunctional, and motor speech assessment/treatment in pediatric/adult populations would familiarize students with these areas prior to, or in conjunction with, observations of these techniques (in schools, clinics, and hospitals). Another survey course on research and scientific thinking would help students develop the habit of accessing and evaluating professional literature to assist in clinical problem solving. SLPAs (speech-language pathology assistants), who are usually trained at an undergraduate (associate or bachelor) level and work under the guidance of certified SLPs, would benefit from a similar foundation.29

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In the “Table 5” model, two courses would be offered on oral sensory-motor assessment and treatment at the graduate level.30 There could be separate pediatric and adult courses on feeding, swallowing, orofacial myofunctional, and motor speech assessment and treatment. As another option, one course could be offered on the assessment and treatment of pediatric and adult feeding, swallowing, and orofacial myofunctional disorders, while a second course was offered on the assessment and treatment of pediatric and adult motor speech disorders.

With a relatively standard curriculum in place at the undergraduate and graduate levels of SLP training, CE courses could provide specialized and updated training in the areas of feeding, swallowing, motor speech, and orofacial myology. Such courses could provide a forum for SLPs to share their expertise, collate their knowledge, establish mentoring networks, and team with members of other disciplines, as appropriate.

CLINICAL IMPLICATIONS

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Speech is a complex sensory-motor act. Yet, throughout the controversy, there was limited discussion of the sensory-motor processes and physical support systems involved in speech production. This was likely related to the fact that the debate initially focused on children with articulation and phonological disorders (who reportedly did not have oral sensory-motor problems). Children with motor speech disorders have now been added to the discussion. Specific information on muscle function, motor programming, and the systems supporting oral function is needed for sound clinical decision-making in the assessment and treatment of these pediatric populations (i.e., children with dysarthria and/or CAS).

Muscle Function, Motor Programming, and Systems that Support Oral Function

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Two “building blocks” of movement (i.e., muscle tone and strength) were discussed by those expressing concerns about the use of NSOMTs and NSOMEs in speech treatment. Children with dysarthria have problems with strength and muscle tone; however, they were not the target population in the controversy. Strength is directly related to muscle tone. Weakness can result if muscle tone is too high or too low (Hillis & Bahr, 2001; Duffy, 1995). While muscle tone and strength are two crucial aspects of muscle function, movement is an extremely complex process based on equally complex sensory processing.

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Figure 3 is a very simplified, conceptual model of the complex interrelatedness among the many sensory-motor components impacting the treatment of oral movement disorders. Three types of oral sensory-motor treatment (i.e., feeding/oral phase swallowing, orofacial myofunctional,32 and motor speech treatment) are listed toward the left side of Figure 3. Bidirectional arrows indicate a relationship among these treatment areas, as orofacial myofunctional treatment may involve oral phase swallowing and/or motor speech treatment.

Moving toward the right side of Figure 3, ideas are found regarding the potential relationships between muscle tone/function and motor plans/gestures.33 Adequate muscle tone (and the resulting muscle function) along with task-specific motor plans/gestures support the grading, dissociation, and direction of movement used in the task-specific processes of eating, drinking, and speaking. If muscle tone is too high or too low, the body is not ready for precise, differentiated movement. The development of unique and precise motor plans/gestures is based upon this “preparedness for movement.”34 The apparent relationship between muscle function and motor programming may help explain why children with muscle function problems also tend to have motor programming problems (e.g., children with Down syndrome, children with cerebral palsy, etc.).

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Listed on the right side of Figure 3 are some of the components thought to be directly related to muscle tone/function and motor programming. Proprioception (defined as “the inner awareness in the muscles and the joints”) is a likely component of both processes. Eating, drinking, and speaking involve significant tactile-proprioceptive sensory processing (in addition to other sensory processing) and task-specific timing and coordination.

An understanding of the systems in the body that support oral sensory-motor function is also needed to effectively assess and treat children with oral movement disorders. Eating, drinking, and speaking involve several systems. Figure 4 is another very simplified, conceptual model of these systems. Intelligible speech requires adequate respiratory and vocal support in addition to control over the oral and nasal areas. Effective eating and drinking require oral, nasal, and respiratory control as well as adequate pharygeal and esophageal function. The arrows in Figure 4 indicate the general direction of movement through the various systems that support eating, drinking, and speaking.

​

Figures 3 and 4 provide the background for subsequent discussions on phonological and articulation disorders vs. motor speech disorders. These figures serve as a simple reference and reminder of the complex sensory-motor bases for the functional processes of eating, drinking, and speaking.

REFERENCES

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APPENDIX A

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Summary of ASHA’s N-CEP EBSRs on Nonspeech and Behavioral/Nonfeeding/Nonswallowing Oral Sensory-Motor Treatment

APPENDIX B

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Summary of ASHA’s N-CEP EBSRs on Nonspeech and Behavioral/Nonfeeding/Nonswallowing Oral Sensory-Motor Treatment

 

APPENDIX C

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Survey for Future Research:State of Residence:________
Diane Bahr, MS, CCC-SLPToday’s Date:____________

Many specific questions regarding oral motor treatment became apparent from studying the likely root of the oral motor controversy, the “Survey on Oral Motor Treatment,” and the review of oral motor journal literature.

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Circle questions important to you. Write other questions you have.

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1. Would a clear definition of oral motor function and the many aspects of oral motor treatment (i.e., feeding/oral phase swallowing, motor speech, orofacial myofunctional treatment, oral awareness/discrimination, and oral activities/exercises) help researchers and clinicians use the terminology more accurately?

2. How can SLPs become more cohesive as a profession? Could group-design research projects combining the efforts of researchers (often doctoral level SLPs) with SLPs who carry active caseloads (often master’s level SLPs) be developed?

3. What is being taught at the undergraduate and graduate levels on feeding, motor speech, and mouth function? Are students still being taught how to adequately conduct, interpret, and use the results of an oral examination?

4. How can continuing education better meet the needs of working therapists? Is there a way to better coordinate undergraduate, graduate, and continuing education on the topic of oral motor assessment and treatment as well as other topics?

5. Is there a professional interest in an updated text on oral motor assessment and treatment? Should researchers and practicing clinicians collaborate on this?

6. Is there an appropriate place and use of nonspeech and/or nonfeeding oral treatments with appropriate populations? What is this place and use?

7. What other related questions do you have?

ENDNOTES

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1 Ages and Stages, LLC; Las Vegas, NV

2 Tip of the Tongue Speech and Language, LLC; Ballwin, MO

3 Academics are “member[s] of an institute of learning” (Woolf, 1980, p. 6).

4 “Narrow” is a descriptive term meaning “to decrease the scope or sphere of” (Woolf, 1980, p. 758).

5 The Oral Motor Institute (OMI) studies the “oral sensory and motor components of articulation, motor speech, and feeding development, disorders, assessment, and treatment.” Retrieved October 30, 2010 from www.oralmotorinstitute.org/index.html. The all-volunteer OMI study group had over 1100 members as of February 24, 2011 (S. Marshalla, personal communication).

6 T. Schooling, personal communication; March 14, 2011.

7 Schooling, personal communication; March 14, 2011.

8 Robey and Dalebout (1998) described meta-analysis as “a mathematical synthesis of independent research findings scattered throughout a body of literature” (p. 1228).

9 LSHSS is ASHA’s Language, Speech, and Hearing Services in Schools journal.

10 It may also be helpful to survey the populations this small percentage of SLPs treat. Do they treat children with phonological and articulation disorders, children with motor speech disorders, etc.?

11 Retrieved October 30, 2010 from www.oralmotorinstitute.org/index.html.

12 Most of the OMI board members are experienced master clinicians and 2 have PhDs.

13 One of the items listed by Lass and Pannbacker (2008, p. 416, Table 6) was Bahr’s peer-reviewed textbook (Oral Motor Assessment and Treatment: Ages and Stages, 2001). The textbook covers a full range of oral sensory-motor assessment and treatment topics including anatomy, physiology, neurology, feeding, and motor speech. Another item listed was a clinical article “Development of Oral-Motor Skills in the Neurologically Impaired Child Receiving Non-Oral Feedings” by Suzanne Evans Morris (1989). These items did not appear to fit with the other items in the Lass and Pannbacker list.

14 “SPEECH-MOTOR ACTIVITY – any therapy activity involving the use of the oral musculature (e.g., lips,…mandible, cheeks, [and] velum) that INCLUDES the production of speech sounds at the same time” (P. Flipsen, personal communication, February 17, 2011).

15 “NSOMTs focus on nonspeech movements of the speech mechanism such as exercise, massage, blowing, positioning, icing, sucking, swallowing, cheek puffing, and other nonspeech activities” (Lass & Pannbacker, 2008, p. 411). Therefore, techniques incorporating speech sound production are not considered NSOMTs.

16 NSOMEs were defined as “any technique that does not require the child to produce a speech sound but is used to influence the development of speaking abilities” (Lof & Watson, 2008, p. 394). Therefore, techniques incorporating speech sound production are not considered NSOMEs.

17 Prompts for Restructuring Oral Muscular Phonetic Targets (Hayden, 2004, 2006)

18 Definitions listed and discussed in Part II (Bahr, 2011b).

19 AJSLP is AHSA’s American Journal of Speech-Language Pathology.

20 JSLHR is ASHA’s Journal of Speech, Language, and Hearing Research.

21 Dr. Paul R. Rao (2011 ASHA president) recently wrote about the importance of “mentorship” in the SLP field (August 30, 2011; ASHA Leader).

22 Oral Motor Assessment and Treatment: Ages and Stages (Bahr, 2001) seemed to be the only textbook covering the many aspects of oral sensory-motor assessment and treatment in one source.

23 Consumers are SLP students, clients, patients, and appropriate others.

24 A number of clinical textbooks have been recently published on motor speech and swallowing disorders. Recent tutorials (applicable to oral sensory motor assessment and treatment) were published by Clark (2003) and Maas, Robin, Austermann Hula, Freedman, Wulf, Ballard, and Schmidt (2008).

25 Dynamic Temporal and Tactile Cueing (DTTC) is a recent example of a motor speech intervention with an empirical evidence base (Strand, Stoeckel, & Bass, 2006). The Verbal Motor Production Assessment for Children (VMPAC, Hayden & Square, 1999) is a recent example of a pediatric, motor speech assessment with an empirical evidence base (as discussed by McCauley and Strand in 2008a). However, data is needed on SLPs’ clinical experiences and the value patients and clients place on these techniques to complete the EBP requirements.

26 Available from www.asha.org/academic/curriculum (ASHA, n.d.-d); no motor speech curriculum resources were provided in this document.

27 ASHA’s 2011 president Dr. Paul R. Rao (March 2011, p. 23) expressed the following benefits of SIGs which could apply to all training levels: “There is benefit in connecting with colleagues who share our interests and expertise, but we gain much more when we also use our collective knowledge to advance the goals and objectives of the entire organization.”

28 Personal communications from E. Palumbo (October 30, 2011) and P. Taylor (October 29, 2011)

29 McNeilly (2010); L. McNeilly, personal communication (July 5, 2011)

30 ASHA’s 2009-2010 Academic Year State-by-State Data on Graduate Education in Communication Sciences and Disorders revealed 266 SLP master’s programs and 83 doctoral SLP programs in the USA (n.d.-c, p. 17, Retrieved May 28, 2011 from www.asha.org/academic/HES/HESDataReports.htm).

31 Normal Development of Functional Motor Skills: The First Year of Life (Alexander, Boehme, & Cupps, 1993) contains topics that may be taught in such a course.

32 Orofacial myofunctional treatment focuses on normal tongue resting posture and oral phase swallowing as well as related dental and speech concerns. ASHA (1991, 1993a) published official guidelines for this type of treatment.

33 The use of the terminology “motor plans/gestures” reflects recent discussions on motor learning theories (Bahr & Rosenfeld-Johnson, 2010).

34 Leslie Faye Davis; personal communication; July 15, 2011

35 See Part II (Bahr, 2011b).

36 Areas of expertise based on published information by these individuals.

37 “NSOMTs focus on nonspeech movements of the speech mechanism such as exercise, massage, blowing, positioning, icing, sucking, swallowing, cheek puffing, and other nonspeech activities” (Lass & Pannbacker, 2008, p. 411). Therefore, techniques incorporating speech sound production are not considered NSOMTs.

38 NSOMEs were defined as “any technique that does not require the child to produce a speech sound but is used to influence the development of speaking abilities” (Lof & Watson, 2008, p. 394). Therefore, techniques incorporating speech sound production are not considered NSOMEs.

39 Different outcomes may have been found if motor speech researchers were matched with clinicians treating mostly children with motor speech disorders and if phonology researchers were matched with clinicians treating mostly phonological disorders.

40 For example, D. Bahr and G. Lof were both instructors in SLP graduate training programs when Bahr wrote the textbook Oral Motor Assessment and Treatment: Ages and Stages (2001) and Lof began expressing his concerns regarding NSOME (2003). Both appeared to want parameters for the use of oral sensory-motor activities/exercises. This may have been common ground from which these two SLPs could have worked.

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Please cite this article as:

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Bahr, D., & Banford, R. J. (2012). The oral motor debate part III: Exploring research and training needs/ideas. Oral Motor Institute, 4(1). Available from www.oralmotorinstitute.org.

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