Great articles by CHERAB advisor Sara Rosenfield- CCC SLP

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Advance for Speech-Language Pathologists & Audiologists

Part I: Straws - Using Simple Tools in Oral-Motor Therapy

By Sara Rosenfeld-, MS, CCC-SLP, and F. Manning

Film writers and novelists know that one quick path into a story line

is through the reliable, dramatic tool of food. Oral-motor therapists

are no different.

This article is the first of a two-part series exploring the use of

simple tools to facilitate therapy for a variety of speech disorders.

The use of straws is addressed in this article, and applications for

horns in oral-motor therapy will be discussed in the second article,

which will appear in the May 31 issue of ADVANCE.

Straws can be used by many clients. The primary goal of the use of

straws is to address insufficient tongue retraction. This treatment

encourages increased speech clarity, whether the client has an

interdental lisp or other phoneme distortion.

Therapeutic straws also have been found to be useful when working

with patients who have velo-pharyngeal insufficiency or are

recovering from a cerebral vascular accident (CVA). In these

instances and numerous others, specially gradated straws are used in

a hierarchical succession to work on a specific component of oral

movement

The use of straws in speech therapy is not uncommon. For many years

straws have been an important utensil in feeding and lip-rounding

exercises.

On the client's level, the straws themselves are viewed as fun, and

the food is experienced as a reward. At the therapeutic level, straws

have the promise of addressing a multiple array of disorders and

muscle groups far beyond traditional practice.

A little over 12 years ago, while initially using straws for feeding

or lip-rounding goals, I was struck by the improved tongue retraction-

-and, therefore, speech clarity--that was its side effect. Since

then, straws have become one of my most important therapy tools.

Traditional therapy methods start with the assumption of adequate

tongue muscle function. Using a multi-sensory approach, the premise

of traditional therapy would follow that if you listen to me when I

say " ball " (auditory stimuli), look at a ball when I say it (visual

stimuli), and hold the ball (tactile stimuli) when I say it, you will

acquire the ability to say " ball. "

Oral-motor therapy does not work like that, particularly with our

special education clients who have reduced visual or auditory

capabilities. Oral-motor therapy asserts that the translation of this

tactile information has to take place in the mouth. Therapists must

put something into the client's mouth that will increase awareness of

the mouth and strengthen the target muscle groups in a series of

measured progressions. This oral muscular development and control is

an important prerequisite that enables the clinician to use

traditional articulation therapy.

Let's review some basics. In English, in order to have connected

speech (co-articulation) and speech clarity, we have to stabilize the

back of our tongue on the back of the palate. Whatever else our

tongue is required to do, it moves from that position of stability.

The tongue elements work with four basic movement components:

* retraction/protrusion,

* back elevation/depression,

* tip elevation/depression, and

* the ability to spread the sides of the tongue.

At birth, babies have approximately a 50 percent back and 50 percent

forward movement from the resting position called a suckle. As

children get older and begin spoon and cup feeding, they achieve

about a 75 percent retraction and 25 percent protrusion. They do not

stick their tongue out during feeding.

Those who do frequently present with feeding problems. Straws have

been prescribed routinely for these occurrences because, at the very

least, the client can return to the 50-50 suckle through straw

feeding.

But there is no reason to stop there, and I would argue that allowing

clients to suckle straws is therapeutically wrong if treatment stops

there. Suckling actually can exacerbate protrusion of the tongue.

It should be mentioned that sippy-cups, a popular feeding tool,

encourage suckling, once again falling short of the preferred 75

percent/25 percent retraction/protrusion goal.

By continuing to use a progressive series of increasingly more

complex straws and thicker liquids, we can teach the tongue muscle to

retract. The goal is to achieve close to a 75 percent retraction to

achieve that position of stability. The back of the tongue in

stabilized retraction allows the tip of the tongue to move side to

side to alternating back molars, the very movement that is needed to

chew food effectively.

At this milestone we have clients who attain more eating independence

and improved nutrition--both very important for children who have not

progressed well with cups or spoons.

How do therapeutic straws address speech clarity goals? Children or

adults with interdental lisps are missing this important component of

stabilized tongue retraction. Clients who stabilize their tongue at

the front of their mouth between their teeth, rather than in the

retracted position of stability, are said to be fronting their

sounds.

If a client is using an interdental production on /t/, /d/ or /n/,

which are the first stable retracted sounds in the developmental

scale, the mastery of these sounds must occur before attempting to

master /s/ or /z/. If a developmentally normal 3-year-old

interdentalizes on /n/, there is already a problem.

In fact, any 3-year-old with an interdental production on /t/, /d/

or /n/ needs help to retract the tongue. Further, any child with an

identified speech problem who suckles, whether it's a bottle, cup or

straw, is maintaining speech errors if they are secondary to

interdental tongue placement.

If a developmentally normal 4-year-old does not interdentalize

on /t/, /d/ or /n/ and has correct tongue blade retraction but lisps

on /s/, it is possible that the lisp is secondary to a developmental

delay and may not need therapeutic intervention.

How do we get clients on therapeutic straws, and at what age or point

in therapy should they begin? Muscles can be toned at any age, 1 or

100. These techniques will work anytime; however, the younger the

client, the easier.

Young children with an identified dysfunction often can be started as

early as 1 year old. Many of our clients with Down syndrome are

started this early because we are working on the concept of

retraction as a critical oral-motor skill that cascades into other

oral-motor benefits.

Other clients with a low-tone diagnosis also benefit from this early

intervention. Many of these children are still on a bottle at ages 2,

3 or 4, suckling. In virtually all cases, straw therapy can be

successfully undertaken by the age of 2.

Some children need an assisted transition. I use a squeezable " honey

bear, " emptied, cleaned, filled with slightly thickened liquid, and

retrofitted with a straw. The child can clutch the bottle while

learning to draw liquid up through the straw. The caregivers of low-

tone children who may not be able to pull liquids up on their own

initially can assist by gently squeezing the liquid up.

Normal straw drinking requires complex movement from the jaw, lips

and tongue. Through the coordination of these movements, a vacuum

draw is created. Each of our speech sounds are made with a different

combination of these graded movements.

Over many years I developed a successional group of straws, with each

individual straw working on a specific part of those graded

movements. After initial experiments with ordinary straws, which

offer such limited results as to be therapeutically unusable, I

located every conceivable type of straw produced and jury-rigged them

when necessary.

Ultimately I was compelled to persuade straw manufacturers to custom-

produce a few of the straws for the specific attributes that I

needed.

This hierarchy of straws progresses through a matrix that advances

from multiple sips to single sips and from thin liquids to thickened

liquids while varying the diameter, overall length and structural

complexity of the straw via elbows, curves, twists, and placement of

a lip block.

At the outset of therapy--making sure that clients are sitting up

straight in a stable position receptive to drinking--I provide a

simple, straight straw of regular diameter to see how they will use

it, allowing them to drink from it like they normally would. I place

my finger at the point where the straw is entering the mouth so I can

take the straw out and measure the length from the entry point to the

tip of the straw inside the mouth.

There are several things to watch for at this stage. Is the straw

more than one-fourth to one-half of an inch inside the mouth? If so,

the client is either suckling or biting it. Biting the straw can be

an indication of jaw instability. The correct position for the

therapeutic use of the straw is with jaw stability, tongue retraction

and lip rounding to fully enable drawing.

The first straw in my hierarchy is cut to the length that I measured

above. The straw has a lip block that encourages sealing and

rounding.

Over a succession of visits, as the client exhibits proficiency,

surreptitiously reduce the length from the lip block to the internal

tip until the client has achieved primary retraction and at least

minimal lip rounding. At this point the client is said to be

therapeutically drinking from a straw, and I am free to move through

the remainder of my hierarchy.

Clients are taking these straws home and using them daily for

drinking all thin liquids. As they progress, thickened liquids and

purees are introduced using specifically identified straws in the

hierarchy. The clients use these straws to drink three to four ounces

once a day. As each straw is mastered or seems to be too easy, move

on to the next. For some clients this may be as frequently as one new

straw a week.

That might be in the case of a developmentally normal child with an

interdental lisp. For this client a full, successful course of

treatment may last as short as four months. Other clients, depending

on the diagnosis (e.g. cerebral palsy), the therapy, while still

effective, may continue for a longer period of time.

A client with Down syndrome may complete the full treatment in one to

two years. We often find that this type of therapy reduces the

duration of speech therapy as they get older.

Clinicians who are targeting specific sounds in therapy with their

clients will find that therapeutic straw treatments have proven to be

effective with the standard production

of /t/, /d/, /l/, /n/, /k/, /g/, /s/, /z/, /ch/, /sh/, /j/, and /r/.

Clients with velo-pharyngeal insufficiency comprise another

population that benefits from straw drinking. For them it increases

tongue retraction and changes resonation and elevation of the velum.

Clients recovering from a cerebral vascular accident (CVA) often

exhibit lip asymmetry. Therapeutic straw drinking works to bring

their lips to symmetrical midline, thereby improving speech clarity.

An extra advantage of treatment through therapeutic straw drinking is

that it can be equally effective with clients, irrespective of

cognitive abilities. The therapeutic results--tongue retraction and

tongue grading--for a client with severe cognitive impairment and

limited or no language skills can be almost the same as with a

developmentally normal child or adult. This adds to its promise as an

important tool in the arsenal of all oral-motor and speech-language

pathologists.

Sara Rosenfeld- is owner and director of Innovative Therapists

International, 3434 E. Kleindale Rd., Ste. F, Tucson, AZ 85716; (520)

795-8544; (520) 795-8559 (fax); e-mail: oromotorsp@...; or

www.oromotorsp.com on the web. Manning is a freelance writer.

Advance for Speech-Language Pathologists & Audiologists

Part II: Horns - Using Simple Tools in Oral-Motor Therapy

By Sara Rosenfield-, MS, CCC-SLP, and F. Manning

If horns had not been invented by ancient civilizations, surely

speech-language pathologists would have had to invent them. From

didgeridoos to trumpets, the controlled use of wind for the

production of phrased sound anticipates oral-motor therapy in more

than tidy, metaphoric allusion.

To some it is hard to believe that a simple toy horn could be

something other than a plaything; but in the realm of speech-language

practitioners, small, unsophisticated horns are effective therapy

tools. These devices can be used to correct articulation disorders,

deal with deficits in phonation and breath control, work with cleft

palate repairs, teach velopharyngeal functions, and improve speech

clarity.

When a muscle cannot perform a specific skill, such as lip closure,

that muscle needs exercise. This is the work of oral-motor therapy:

to normalize oral musculature through exercise. Traditional speech

therapy without the proper muscle control cannot be completely

successful.

However, it is equally important to remember that oral-motor therapy

is an adjunct to traditional therapy, not a replacement. When the

targeted muscles do normalize, the introduction of traditional

methods such as auditory feedback or phonological processing

approaches attain measurably higher degrees of success. Using toy

horns as therapy devices to achieve that goal is powerful and fun.

In the last 15 years I have experimented with more than 80 horn-type

devices to identify which ones work on targeted muscles and which

ones can be used on an abdominal airflow hierarchy. That work has

evolved into a program that includes 14 progressively complex horns.

This hierarchy works on designated goals such as correcting an

interdental lisp, improving lip rounding, and working on specific

phonemes. It deals with the development of muscles in three areas in

this order: phonation through the abdominal muscles, resonation

through muscles of the velum, and articulation via the muscles in the

jaw, lips and tongue.

There are two broad patient categories. Some clients start at the

first horn and work to complete the entire hierarchy, while others

have specific needs that can be treated by the use of individual

horns to address their personal speech deficits.

Those clients who lack grading in only the jaw, tongue or lip are the

least impaired. Those who have deficiencies in velopharyngeal closure

must address those defects before the jaw, tongue or lip issues are

addressed. Those with abdominal deficiencies are, for the purposes of

this discussion, considered the most severely impaired.

Clients with more severe problems start with the first horn and

successively master each one until they reach the final horn. This

approach would be suitable for clients with cerebral palsy or Down

syndrome and could take as long as two years.

Clients who are less severely impaired may start with a specific horn

at a predetermined point within the hierarchy to address specific

goals. This gives the clinician a methodic, scientific way to create

an individualized program for each client that often is completed in

four to five months.

These exercises can be used by clients of all abilities and age

groups. I have used them with clients as young as 12 months and as

old as 104.

The horns are organized by goals and the muscle movement required to

produce phonemes. Each horn incrementally becomes a degree harder

when working in the hierarchy, challenging the client's achievements

in a rewarding way. They are suitable for schools and other group

therapy environments.

Horns are also an important part of a drooling program because they

address awareness of lips and maintenance of lip closure and teach

retraction of saliva back over the tongue, much of which can be

taught without cognitive cooperation. With horn therapy even our

clients with major deficits make significant therapeutic progress.

At the outset of the program, the therapist introduces a target horn

and determines the highest number of repetitions that can be achieved

in rapid succession at one time without a break. The goal with each

horn is to achieve 25 successive repetitions, taking a small breath

between each blow. If the maximum number of repetitions produced is

less than the targeted goal, the therapist stops and assigns the

attained number as homework.

These exercises should be practiced at least twice a week with the

therapist and at least once a day at home. As each horn is mastered,

the therapist introduces either the next horn in the hierarchy or the

next horn appropriate to the client's goals.

Parents and caregivers assist the client in practicing homework. It

is vitally important that they be assigned a meaningful role in

treatment. Many of our young patients who are cognitively impaired

can barely interact with their parents. Involvement in this homework

gives them an easily fulfilled assignment that provides immediate

emotional and therapeutic feedback for the child and the

parent/caregiver.

A brief review of a few specific horns will help in understanding

their interaction in the hierarchy and some of their unique

attributes.

The first horn is so easy that it requires almost no abdominal

constriction and no constriction of the obicularis oris muscle. It

produces sounds almost from the client's vegetative breathing. This

horn teaches jaw elevation with minimal lip closure as the client

learns to volitionally control airflow. Outside of the hierarchy, it

improves the production of the sounds /m/, /b/, and /p/.

The second horn is a harmonica-like device that teaches further lip

closure and the skill of projecting exhalation in a frontal manner.

By gradually covering up the side holes until only the central holes

remain exposed, clients can feel--and hear--the redirecting of

airflow to the very front of the lips. Used alone, this instrument

works on the standard production of /s/ by assisting in the

correction of a lateral lisp.

The third implement is similar to a slide whistle. It requires more

than elementary lip closure and teaches first-level lip rounding for

the production of /w/, /oo/, /sh/, /ch/, and /j/.

The fourth horn has a flat mouthpiece and must be blown for a one- to

two-second duration. These variations increase the abdominal and lip

closure difficulty and further the work on production of /m/, /b/,

and/p/ and the prolongation of oral language statements.

The fifth, sixth and seventh horns address additional prolongation of

sound, bilabial sounds, oral-tactile defensiveness, and low jaw

sounds required for vowels and open-mouth consonants. Horns eight and

nine work on bilabial sounds and tongue retraction. The latter is

also an important tool for clients working on oral-nasal contrasts,

especially after cleft palate repair.

Horns 10 through 14 work on intensifying the degree of duration of

exhalation, lip rounding, lip protrusion, tongue retraction/release

and abdominal constriction/tension. They specifically target the

correction of the interdental lisp.

Horns are fun, and fun is a motivator. Part of the success of this

therapeutic approach is that this is work--difficult work for many

clients. However, the work is disguised as a toy, and the fun clients

have repetitively using the toy is exercise.

Recreating a muscle movement through the element of repetition is our

goal with each horn used. Certain rules must be followed:

* The client's feet must rest firmly on the floor or other

stabilizing surface, and the body should ideally achieve 90-degree

angles in the pelvis, knees and ankles.

* Hold the horn and make sure there is no biting.

* Remove the horn from the client's mouth after each blow.

The first rule does not vary, whether clients are in a chair,

wheelchair or prone-stander or whether the therapist is working with

them over therapy balls or bolsters. Stabilization in the body allows

for mobility in the mouth.

Consult with a physical or occupational therapist to achieve maximal

positioning. This postural work has been traditionally in their

realm. However, for the purposes of these exercises, it is now ours,

too. During all therapy sessions and homework with a client, it is

important to maintain this maximal posture.

The second rule is needed because the horns will become toys and

rendered ineffective for therapy if they are not used correctly. If a

therapist simply hands a horn to a child, the client's first reaction

will be to put it in the mouth and bite on it. Biting eliminates the

therapeutic jaw-lip-tongue dissociation component of horn therapy.

Beginning with the ninth horn, clients who are cognitively involved

with the therapy and show they are capable of following directions

can hold the horns by themselves while the therapist continues to

monitor posture and placement. For older children and adults,

therapists should use their discretion based on diagnosis and

cognitive ability.

Finally, therapists must remove the horn from the client's mouth

after each blow. This therapy requires repetition. Muscle movement is

recreated over and over again to develop strength/muscle memory. The

goal with each horn is to be able to blow, with controlled

exhalation, successive repetitions and for the jaw, lips and tongue

to successfully reposition prior to each blow.

The client populations that benefit from these techniques are

diverse. Clients who have a diagnosis of apraxia/dyspraxia can use

horn therapy to learn motor-planning movements for the eventual

development of speech clarity. These methods sidestep their

deficiencies. The stimulus-response technique of the horn creates the

muscle action allowing the muscle to take that movement into memory.

Clinicians can put their hand on a client's stomach and push inward

during an exhalation, getting the air to go through the horn and

produce sound. This gives the client a new awareness that what

happens in their abdomen creates sound from their mouth. Clients who

are cognitively impaired gain this same awareness devoid of verbal

instruction.

Many clients of various diagnoses have insufficient ability to

contract and grade their abdominal muscles. They must learn to

tighten them in order to control their exhalation. Low tone in their

abdominal muscles produces insufficient amounts of air that only

support single words or short phrases. Horn therapy assists to

accomplish this without using compensatory skeletal movements such as

shoulder elevation and/or whole body tightening.

These are just two categories of clients whose problems have not been

adequately addressed by traditional speech therapy. The result has

been a significant inhibition of the clients' ability to express

themselves at their cognitive level.

When the horn therapy program is completed, clients have the strength

and mobility to start traditional articulation therapies. And they

got to make a little music along the way.

Sara Rosenfield- is owner and director of Innovative

Therapists International, 3434 E. Kleindale Rd., Ste. F, Tucson, AZ

85716; (520) 795-8544; 888-529-2879; e-mail: oromotorsp@...; or

on-lind: www.oromotorsp.com.

Manning is a freelance writer.

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