Join us as we explore research purported to disprove the effectiveness of oral motor therapy. Discover valuable talking points in defense of oral motor therapy so you can take an informed stand! The information for this podcast was gathered from Char Boshart’s series “The Perfect Oral Motor Storm.”

Show Notes & Links

To Motor or Not to Motor
Our previous podcast on NSOM and the controversies surrounding it.

Char Boshart’s Podcasts
https://speechdynamics.com/pages/podcasts
(episodes 33-37 comprise The Perfect Oral Motor Storm: What Happened, Why, and Supportive Evidence of Oral Sensory-Motor Methods to Remediate Speech Sound Productions)

The Perfect Oral Motor Storm Articles
https://speechdynamics.com/pages/articles

Impossible R Made Possible
Online Course

Music: Simple Gifts performed by Ted Yoder, used with permission

Transcript

Dan: Welcome to The Mindful SLP, the podcast for SLPs looking for simple tools and optimal outcomes. Your host is Denise, experienced speech therapist, specializing in all things pediatric, and Dan, business manager for her private clinic.

Denise: Hello, welcome back, and thanks for listening to us today, we are going to take a deeper dive into the oral motor therapy controversy. Now the last podcast we talked about it and I discovered I have more to say, enough to make a whole nother podcast. So here we are.

Dan: Believe me, she has more to say.

Denise: So, if you didn’t hear our last podcast, episode six, it was called to motor or Not to Motor, that is the question. And we talked about, as I said, the oral motor controversy in our field, and I recommended listening to Char Boshart’s podcast series on it. She has produced a five-part podcast called The Perfect Oral Motor Storm. In it, she really delves into the research around this whole controversy.

And when we did our last podcast To Motor or Not to Motor, I had just started listening to hers, but I hadn’t completed them. So I thought, okay, now I’ve got to listen to all of them. And I was dumbfounded. I was flabbergasted by the quality of what people were calling evidence against oral motor therapy.

Dan: So let me set the picture for those out there listening. After we wrapped up the podcast, last time I went up to my office and I started editing the podcast and putting everything together. And every few minutes Denise would just come blowing into my office, “can you believe this?”

Denise: Okay. I couldn’t contain myself, I had to share it with someone.

Dan: Well, after the third or fourth explosion I had to ask. Was I wasting my time here? Should I just scrap the last podcast? Was I wasting all this effort on this because you obviously had more you wanted to say, and, and so that’s why we’re doing this podcast. So why is this important? You covered your opinion pretty thoroughly before, but what more do you have to say?

Denise: I need to do another podcast because I need to be able to defend my position with more than ‘because I’ve seen it work’. Okay, that’s easy to discount, um, especially when people believe that the answers are signed, sealed, and delivered. If all you have is your own knowledge and you don’t know what the research out there is saying specifically, I didn’t know what the research was saying against oral motor therapy. I was pretty happy in my old world. I know Prompt works, I know my oral motor exercises for my Impossible R Made Possible program works. I know tongue-thrust therapy works. So why should I care what you guys say? Well, it turns out I do need to care.

Dan: So what are we going to cover today?

Denise: We’re going to cover the high points from Char Boshart’s podcast and articles. By the way, she’s got five articles that go with the five podcasts. Um, there’s far too much material for me to go in depth and there’s no need to because Char has done it all. She’s done an amazing job, but if you want some talking points, this podcast might help you.

Now I want to explain that The Perfect Oral Motor Storm focuses on the controversies surrounding non speech, oral motor exercises. And I’m a Prompt trained therapist, but I also use non speech oral motor exercises in my R program. I use them with tongue-thrust therapy. The underlying principles are the same in all of these kinds of therapy.

So I might talk about Prompt some and Prompt would escape the controversy around oral motor exercises. We do words or sounds that can be morphed into words as I’m saying the foundation’s the same. So I’m including all that in there.

Dan: All right, let’s start at the beginning then. How did this controversy start? Has oral motor therapy always been looked at askance?

Denise: No, it hasn’t. This really began in the early 2000’s, about the time evidence-based practice became the word of the day. Before that time, sensory motor therapy was not questioned. Um, therapists have been doing it for more than a hundred years.

Dan: Oh, a hundred years. So oral motor therapy even predates you. So this is a fairly recent development, then we’ll explain evidence-based practice to me. It’s pretty straight forward the way it sounds, but is there more to it than meets the eye?

Denise: There is, and I love to explain it because it’s a little different than some clinicians might understand it. Evidence-based practice originated in the medical community.

The ASHA definition is very like the medical one. ASHA’s definition reads “the term evidence-based practice refers to an approach in which current high quality research evidence is integrated with practitioner expertise and client preferences and values into the process of making clinical decisions.”

Dan: Okay, so research is integrated with practitioner expertise and client preferences.

Denise: And one of the committee members who helped write this definition pointed out that some parts of evidence-based practice definition sometimes get more attention than individual clinical expertise. Can you guess which piece gets more attention?

Dan: Let’s see, the researchers probably want to focus on, I don’t know, research.

Denise: Yeah. That’s exactly. So our advancement as a profession suffers when we fixate only on the research. The successes we experienced working with clients ought to guide our research instead of stifling innovation. As clinicians, we know when something is working.

Dan: If something is working, then we need to find out why it works.

Denise: Right, instead of research being used as a bludgeon and a way to shame clinicians for not understanding the evidence.

Dan: Evidence really should be driving what the researchers are looking into and what they’re going to research next. Well, does ASHA have a position on oral motor therapy?

Denise: Yeah, they do. That’s a great question. Listen up clinicians here is a talking point. ASHA does high-quality impartial research reviews called Evidence-Based Systematic reviews, EBSRs for short. The one they did on oral motor exercises has this conclusion: Insufficient evidence to support or refute the use of oral motor exercises to produce effects on speech was found in the research literature.

Dan: Okay, I studied physics for several years and that wording tells me this: we won’t take a stance until someone does, does more research. The old adage of absence of evidence is a logical fallacy. We aren’t saying yes, we aren’t saying no. It’s actually a challenge to both sides of the argument to get out there and do more research because the research we have just isn’t cutting it.

Denise: And that’s true, and when ASHA does these, um, EBSRs, they’ll look at a lot of studies and many of them have to be discounted because they aren’t meeting their criteria. So you might have 200 studies and out of them, ASHA can only use 15.

Dan: So we need to do better job of setting up our studies.

Denise: Yes. And so that’s, Char goes through lot of those. And so you can see why, um, there’s insufficient evidence. And did you know, according to one study cited by Char, the more than half of all medical treatments and perhaps as much as 85% have never been validated by clinical trials.

Dan: What else out there hasn’t been proven?

Denise: Our language intervention practices, for one. According to a comprehensive review done in 2008, no studies support language intervention in middle school and high school. And there’s limited evidence for what we do at the elementary level. That’s really sobering, when you think about that.

Yeah, we haven’t stopped doing language therapy, so it seems like the oral motor piece has been singled out as ‘do not do that because we don’t have the evidence for. it.’ But actually there’s so many things we do that we just don’t have sufficient evidence for. But we’re not going to stop doing what we internally know what works.

So to quote Char, a lack of external research evidence does not mean there’s a lack of internal therapeutic evidence. I have seen the internal therapeutic evidence on oral motor therapy, but we do need to understand what is out there.

Dan: Right. Well, what about those studies that appear to have proven the ineffectiveness of oral motor therapy? How did they come to that conclusion?

Denise: Okay. This is what had me storming into the office, a creative interpretation of non speech oral motor exercises for one. Um, for instance, one study had kids walk around the room. Just absorb that. Walk around the room. They called that an oral motor exercise. They had them pat their cheeks. Um, we had someone stroke their tongue with a tongue-depressor. Well, no surprise, the study found that their speech did not improve after these exercises.

Dan: So the exercise really wasn’t even necessarily connected to speech. Yeah. I’m not a speech therapist but that just doesn’t sound quite right to me. That that would be a good study. I mean, I would hope that you wouldn’t teach somebody that the only way they could talk is to walk around a room.

Denise: Yeah. I mean, there’s an assumption by some researchers that any random exercise fits in the category of oral motor therapy and that they can be implied equally across the speech impaired population, regardless of age or disorder, there was no personalization to the child, no description of what particular motor skill the exercise was supposed to target. A few people would be surprised at the outcomes of a study constructed this way.

Dan: I can see why you exploded into my office.

Denise: So by contrast, when I video a new client and review it for a Prompt analysis, I spent a lot of time analyzing what area of motor development I need to target. I’m looking at how their jaws moving, I’m looking at their range of motion. I’m looking at so many things and I watched the video multiple times. It’s the least random thing I can think of. There’s a real methodology to what we do, and that has been dismissed by some researchers. And some studies ignored the sequence of development. So you speech therapists know those later developing sounds the R the L the ch the J there was one study that used young children, like around three and four years old, had them do some oral motor exercises and then tested them on these later-developing sounds. Surprise surprise, no improvements. Um, have we forgotten, like Char said, have we forgotten the sequence of development, did we just throw that out the window? So such approaches feel dismissive to us, clinicians in the field as though someone decided oral motor therapy was wrong and set out to prove it without taking the time to talk to therapists, who’ve seen it work and saying, well, what do you do? I’d like to study what you do

Dan: Besides these studies are there objections to the theoretical basis of oral motor therapy?

Denise: Yes, there are. And I love to talk about these because I hear these all the time. Okay. So one of the objections is that part to whole learning doesn’t work. The argument is, breaking down a complex task, into smaller pieces doesn’t help with learning.

That just sounds

Dan: totally wrong to me.

Denise: And Char points out yes, it does. It’s supported throughout the literature and she has examples and by the way, speech is incredibly complex and some of our children really do need it broken down.

That’s how I learn a lot of things, is having to break it down.

Okay, so now here’s the story. You have to follow me through, it’s a kind of a convoluted story, but I think you’ll understand where I’m getting in the end. Um, I was at my state association convention and the presenter was talking about a language approach called statistical learning, and just in a nutshell, you’re presenting the child with varied language targets and their brain can pick up on it the way it’s presented, there’s a real methodology to it, but you’re varying a lot of things that the child is hearing. So an audience member raised their hand and said, well, does this apply to articulation therapy? Does this apply to motor learning principles? I believe what the therapist was wondering is in oral motor therapy, we do do a lot of repetition. Break it down. Repeat it, repeat it. And so she was wondering, well, should there be more variance? Will they learn better that way? And the presenter now, this articulation, you know, wasn’t her thing. Right. But she stopped and thought and said, well, there was a study and she described this study of basketball players trying to improve their free throw ability, is it free throws? And they got better when they went to different positions.

Dan: In doing 100 free throws, right from the free throw line, they had to move around

Denise: They had to move around and it showed improvement. Okay. And so she said, well, I think that would transfer to articulation therapy. I think more variance is better. So in my mind, I’m thinking, and I didn’t say this, and I wish I had, it’s about planes of movement. So if you’re working on a sound like maybe R, and you have a lot of variants in the sound and the child is just learning that sound well, even when you change the vowel you might be changing the plane of movement, you already have a whole bunch of variants just if you understand how to look at where the child might be breaking down, when they move to a different plane of movement, that doesn’t really work with the basketball example. Okay. So now to get down to why I even brought this up, I was reading Char Boshart’s article and she starts talking about the basketball analogy.

Um, and so I research her name. Gregory Law(?) Has been very, very active in the I have a call anti oral motor therapy field, and so this is one of his examples I found out by reading it. Char Boshart mentioned Dr. Law’s example at a seminar and an athlete spoke, and said, and I’m quoting her, “when I teach someone to throw a basketball, I deconstruct the movements, they practice and learn the movements, then put them together that works best.

Dan: Golfers do the same thing, by the way, they have their exact swing that they use time in, time out. They just don’t go out there and just whack it. I mean, I’m, I’m an actor and. I do a lot of rapid fire dialogue on stage and the best way we rehearsed that is to slow it down. And then you start speeding up and putting it all together. So it’s not even, it’s not even words, it’s getting the sounds and the movements to start clicking together so that you can get that muscle memory. So then when you go faster, It works.

Denise: So we’ve established part to whole does work.

Dan: I think we beat that dead horse.

Denise: I think we did. But the next argument that people have is around something called task specificity. So there’s a school of thought that speech and non speech tasks originate in different parts of the brain. Therefore it is not helpful to do non speech tasks. Now I see two problems with this. One, this theory has not been proven about task specificity and some take the view that the neural networks overlap.

Okay, now the second problem I see with that is how are you going to define speech? What is it? What’s a sigh, what’s humming? What’s a baby making an mmm sound when they eat and then saying mmm when they see something yummy that they want, a gentle cough, that is meant to communicate something or get someone’s attention as opposed to an actual cough throat clearing and so on.

Um, where are those on the continuum of speech and non speech? It seems like there’s a real overlap and it just bleeds from one area to the other. I have a client who just started with me. And he really doesn’t have very many words at all. And we’ve been working on awe for on, and he said on once and the way he got it is he started with a yawn.

He went ‘aawwwwwwnnn’. He had to access that reflexive movement, and then he was able to get, I’m making you yawn. So where would you put that on the continuum of task specificity? Did he, did he go from one box in his brain to another box in his brain or did the neural networks overlap? Yeah, you can tell what side I’m coming down on.

Um, and by the way, there’s no agreed upon definition of speech in our field, but most include a motor component. Okay. So there’s the argument that non speech oral motor exercises are not relevant, but as therapists we make what we do relevant, that’s what we do all day long. We make things relevant to the client. And here’s an example. It’s not necessarily an oral motor exercise example, but I think you’ll get the hang of it is if I am working with a client on ‘mmm’, that I want to move to from an mmm sound to an umm to a yum. I have this little activity we do with, we put mini marshmallows on little sticks. We roast them over the fire on the iPad.

It’s really fun. But we start with saying mmm, and then we move it to a maybe a semi word, umm, and it’ll be a while before they can move to yum, because that is moving from one plane of movement to the other. You see how I had to deconstruct the word yum. Where is that on this continuum of speech to non speech.

Right. But you can see the activity makes it very relevant to the client. They totally get it.

Dan: They’ll be doing ‘mmm, yum, marshmallows’ forever.

Denise: Yeah. So I would argue that using three systems of feedback, sensory motor, auditory and visual is more relevant to the client, then only using two, auditory and visual. And so, by the way, when I’m doing that with a client, I am prompting them, I’m helping them with their jaw movements and adjustability and the range of motion and giving them tactile cues. So that’s what makes it motor.

Dan: What’s the next one?

Denise: And misunderstanding about the use of warmups. So in sports, we talk about warmups, increasing blood circulation and how they’re helpful when you’re going to maximally tax your system.

So you need a lot of muscle strength for it. The argument is well, in speech you don’t need a lot of muscle strength. Why in the heck are you doing warmups? Well, we don’t do warmups in speech to increase the blood circulation. That’s not why we’re doing them. And you tell me as a singer, why do you do warmups?

Dan: Warmups are all about limbering up your voice, and limbering up the muscles around your mouth so that you can sing and make it. We do jaw movements. We do lip stretches. We do tongue waggles. We do repetitive movements to get them all working together. We start out slow, and then we gather speed and we’re doing things so that we can be understood.

Denise: And so it’s the same with our kids. If we’re doing these motor warmups, we’re preparing them for success in the session, we’re building their capability so that they can be successful and do more in the session. Get more done. Right. So those are the talking points that I came up with. There’s a lot more, but you can go to Char Boshart’s podcasts and articles and find them out yourself.

But one last point Char brought up that I really, really like we have phonologic processes that we use to talk about speech disorders, final consonant deletion, cluster reduction, et cetera. These don’t describe what you want the client to do. They describe what you want them to eliminate. Now, ever since I’ve been doing oral motor therapy, I haven’t written an elimination goal. I haven’t written an elimination goal in years, and it’s really freeing. Now. I describe what I want the client to do.

Dan: It gives them something that they can actually act on. It’s much easier to do something than not do something.

Denise: It is, and as a therapist, it’s just a mind shift, a whole mind shift. Oh, this is why you see why the sound isn’t happening because you see the motor pieces that are missing.

You can put them in and it just makes it so much clearer in your mind about what your end goal is and how to get there. So the takeaway is I’m no longer staying silent. I’m going to weigh in respectfully, but confidently with my point of view. I’m going to be ready to answer questions and also going to ready to take the offensive stance sometimes.

Respectfully, I can say, what role do you believe muscles have in speech production? I can ask how do you define speech or which study disproving oral motor therapy do you favor, and what oral motor exercises did they use in that study? I’m going to stand up for oral motor therapy. So therapists, this is how I feel based on my experiences.

Um, if you are a therapist who has seen success with oral motor therapy and are for it. If you don’t know the research behind it on either side, I would urge you to look up resources like Char, whatever, so that you can reply to people who are anti oral motor therapy. I guess. These talking points are just a way to help you stand up for what you believe in, for what you’ve seen work,

Dan: And you gotta influence it too. I mean, if you don’t stand up and start talking to the people who are doing the research, they’re not going to realize that they need to do research on what is actually being done out in therapy.

Denise: Well, that’s so true. Maybe they’ll understand that they shouldn’t have chosen these specific motor exercises. They could have chosen better ones. They could have constructed the study better. So thanks for listening. Stand up for oral motor therapy.

Dan: Thanks everyone for listening to us this week, we would really appreciate if you would go out and give us a rating on Stitcher or iTunes, wherever you see podcasts.

But more than that, please come to. SLP pro-advisor dot com. Join the conversation there. We would really love to know what you think about oral motor speech therapy, as well as all the other things that we talked about. What do you want us to talk about? What’s you know, what is good for you? Let us know it.

SLP pro-advisor dot com. Thanks for listening. We’ll talk to you next time.

Thank you for listening to The Mindful SLP. We hope you found some simple tools that will have optimal outcomes in your practice. This podcast is sponsored by SLP pro-advisor. Visit SLP pro-advisor dot com for more tools, including Impossible R Made Possible, Denise’s highly effective course for treating those troublesome Rs.

A link is in the show notes. If you enjoyed this podcast, please give us a five-star rating and tell your fellow SLPs. And please let us know what you think. Join the conversation at SLP pro-advisor dot com.