Oral Motor Institute

«Vol. 2, No. 1




Oral Motor Institute
Volume 2, Monograph No. 2, 9 April 2008

ORAL MOTOR TREATMENT vs. NON-SPEECH ORAL MOTOR EXERCISES

Historical Clinical Evidence of "Twenty-two Fundamental Methods"

Peer Reviewers: Diane Chapman Bahr, M.S.; James Paul Dworkin, Ph.D.; Samuel Fletcher, Ph.D.; Daymon Gilbert, M.Ed.; Jennifer Gray, M.S.; Raymond Kent, Ph.D.; Suzanne Evans Morris, Ph.D.; Donna Ridley, M.Ed.; Sara Rosenfeld-Johnson, M.S.; Pat Taylor, M. Ed.. There were no blind reviewers of this monograph.

Reprints: This monograph was reprinted in its entirety in the workshop manual Feeding and Pre-Speech Issues: The Mild and Moderately Involved Child by Suzanne Evans Morris, Ph.D.

This monograph was used in a coursework pack for fall and winter 2008 school term by University Readers. The monograph has been reprinted with the permission of the OMI.

INTRODUCTION

Some speech-language pathologists promote "oral motor treatment" for articulation and/or feeding therapy, while others insist that there is no evidence to support the use of "non-speech oral-motor exercises" (NS-OME) in articulation therapy (Banatoi, 2007, Lof & Watson, 2004, 2008, and Hodge & Salonka & Kollias, 2005). Are these professionals discussing the same thing? Therapy is a process of treatment comprised of techniques. Speech-language therapy includes many treatment techniques including those designed to facilitate improved oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) skills. But several questions arise today: What is oral motor treatment? Is "exercise" the extent of it? Who has advocated these methods? What role have oral motor techniques played in the history of speech-language therapy? Why has the term "oral motor" caused such a firestorm in the profession? Are advocates of "oral motor therapy" attempting to substitute it for articulation or phonological therapy? What does "wagging the tongue" have to do with speech? Why are some practicing speech-language pathologists clamoring for these methods? The current pressing need for scientific investigation of these techniques requires a thorough historical review.

Purpose

The purpose of this literature review was to seek out and report on techniques designed to facilitate improved oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) skills as they have been discussed in clinical speech-language-hearing publications throughout the history of the profession.

METHOD

A set of 84 textbooks, clinical guidebooks, and conference proceedings were reviewed for their oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques (Appendix A). Publications were selected from the following six treatment areas: articulation, phonology, motor speech, feeding, dysphagia, orofacial myology, and oral motor therapy. Three introductory communication sciences texts, and one speech-language guide for parents, also were included in this set. These publications spanned the years 1912 through 2007 and were written in English. Distribution of texts by topic is presented in Table 1.

Table 1. Distribution of texts used in the literature review by subject area.
Subject Number Reviewed
Articulation 35
Phonology 8
Combined articulation and phonology 5
Motor speech (including cerebral palsy) 17
Feeding and Dysphagia 7
Orofacial myology 2
Oral motor 6
Introduction to communication disorders 3
Parent speech-language guide 1
Total Publications Reviewed 84


RESULTS

Many interesting findings were made as a result of this literature review:

  1. Jaw, lip, and tongue facilitation techniques were discussed, described, or recommended in 95.24% (80/84) of the publications reviewed.
  2. There were uncounted hundreds of jaw, lip, and tongue facilitation techniques scattered throughout these publications.
  3. Jaw, lip, and tongue facilitation techniques ranged from the simple to the sophisticated. On one end of this spectrum were simple techniques in which speech-language pathologists merely modeled jaw, lip, or tongue position. On the other end were procedures designed to influence neuromuscular processes (e.g., to influence muscle tone, stimulate oral reflexes, normalize oral tactile sensitivity, and so forth).
  4. Authors represented all educational levels from practicing clinicians, with bachelor's and master's degrees, to full professors. These authors worked in schools, hospitals, private clinics, research facilities, and universities. Eight of these authors served as presidents of the American Speech-Language-Hearing Association (ASHA) (Appendix B).
  5. The term "oral motor" did not appear in any of this literature until 1978. The first publication using the term "oral motor" from this collection was a 1978 publication of the proceedings of a four-day conference held in 1977. The conference was entitled "Oral-motor Function and Dysfunction in Children." (Wilson, 1978).
    1. The conference focused on feeding development, disorders, assessment and treatment, and there was one section on speech.
    2. The conference was multi-disciplinary and included presentations on structure, function and neural control of the oral and pharyngeal mechanism.
    3. The panel included Suzanne Evans Morris, Ph.D., Suzann Campbell, Ph.D., Joan Werner, Ph.D., James Bosma, M.D., Constance Evans, M.A.C.T., Sandra Radka, M.A.C.T., and Janet Wilson, L.P.T.
  6. Publications on ARTICULATION from the first half of the century (1912-1956) openly advocated oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques, and contained advice about their selective application. They contained two types of methods:
    1. Detailed methods designed to stimulate the movements and positions of the jaw, lips, and tongue for the production of specific phonemes. These methods were organized phoneme-by-phoneme and were intended for clients ready to work on one phoneme at a time. These methods became known as the "Stimulus Approach", the "Phonetic Placement Approach," "Motokinesthetics," and the "Integral Stimulation Approach" (For a summary, see Newman, Creaghead, & Secord, 1985, pp.128-129).
    2. Jaw, lip, and tongue warm-up activities designed to prepare the oral mechanism for speech sound movements. These methods were recommended for working with young children, older children with cognitive impairment or motor disability, and others who, for whatever reason, were not ready to work on one phoneme at a time.
  7. Publications on ARTICULATION from the second half of the century (1960-2007) continued to contain information about oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques. They generally represented one of three categories:
    1. Broad-based speech textbooks that introduced both articulation and phonology. These textbooks contained general introductory and cautionary information about the application of these methods for the production of phonemes (e.g., Bernthal & Bankson, 1981 and 2004, and Bauman-Waengler, 2004).
    2. Clinical guides that contained specific oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques designed to solve specific articulation problems (e.g., frontal lisp, lateral lip, persistent /r/ distortion) (e.g., Marshalla, 2004 and 2007).
    3. Clinical guides that contained specific oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques while addressing a cross section of phonemes (e.g., Bleile, 2006, and Rosenfeld-Johnson, 2001).
  8. Publications on ARTICULATION throughout the whole century (1912-2007) utilized a wide variety of terms and descriptive phrases to identify their oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques. For example:
    1. "Tongue gymnastics" (Scripture, 1912, p. 160).
    2. "Maxillary, labial, lingual and velar gymnastics" (Borden & Busse, 1925, p. 159).
    3. "Exercises for weak or relaxed muscles" (Travis, 1931, p. 208).
    4. "Strengthening and stereotyping the motor patterns" (Kantner & West, 1933, p. 350).
    5. "Exercises for gaining control of the speech mechanism" (Nemoy & Davis, 1937, p. 36).
    6. "Visual, tactile, and kinesthetic approaches" (Anderson, (1953, p. 147).
    7. "Improving the speed and precision of the articulatory musculature" (Van Riper, 1954, p. 216).
    8. "Tongue exercises" (Van Riper, 1954, p. 216).
    9. "Definite stimulation to speech muscles" (Young & Hawk, 1955, p. 12).
    10. "Strengthening the visual-tactile cues" (Berry & Eisenson, 1956, p. 138).
    11. "Increasing the flexibility of the articulators" (Berry & Eisenson, 1956, p. 139).
    12. "Sensory-motor procedures" (McDonald, 1964, p. 135).
    13. "Direct manipulation" (Winitz, 1975, p. 71).
    14. "Extraoral and intraoral stimulation technique" (Vaughn & Clark, 1979, p. 3).
    15. "Various approaches ... along the sensory-motor continuum" (Hanson, 1983, p. 152).
    16. "Motor practice" (Ruscello, 1984, p. 130).
    17. "Motor sensory targets" (Borden, 1984, p. 51).
    18. "Physiological approach" (Fletcher, 1992, p. iii).
    19. "Oral motor techniques" (Marshalla, 1992, p. 1).
    20. "Oral motor exercises for speech clarity" (Rosenfeld-Johnson, 2001, p. i).
    21. "Tongue and lip awareness activities" (Bauman-Waengler, 2004, p. 225).
    22. "Oral-motor activities", "oral-motor training", and "oral-motor instructional activities" (Bernthal & Bankson, 2004, p. 333-335).
    23. "Touch cues" (Bleile, 2006, p. 8).
    24. "Methods and techniques that can be used when the client cannot produce a target sound at all" (Secord et al, 2007, p. 3).
  9. Publications on MOTOR SPEECH (including cerebral palsy) spanned the years 1964-1999. They contained a wide variety of oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques organized by:
    1. Body part (e.g., techniques to facilitate movement and position of the upper lip, lower lip, tongue tip, tongue back, tongue sides, head, neck, and so forth).
    2. Sensory and motor process (e.g., techniques to vivify oral movement, improve muscle tone, normalize tactile sensitivity, dissociate movements, stimulate reflex responses, and so forth).
  10. Publications on MOTOR SPEECH disorders, including cerebral palsy, identified their oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques by a wide variety of functional phrases. For example:
    1. "Improving the function of the jaw, lips, and tongue" (McDonald & Chance, 1964, p. 124).
    2. "Activities preliminary to speech production" (Darley, Aronson & Brown, 1975, p. 274).
    3. "Neurospeech therapy" (Mysak, 1980, p. 183).
    4. "Articulation subsystem exercises" (Dworkin, 1991, p.191).
    5. "Muscle training" (Love, 1992, p. 152).
    6. "Improving sensory and motor functions within physiologic processes" (Brookshire, 1992, p. 259).
    7. "Mechanical positioning of the patient's articulators" (Brookshire, 1992, p. 279).
    8. "Oral motor phonetic drills" (Crary, 1993, p. 223).
    9. "Motor programming approaches" (Hall, Jordan, & Robin, 1993, p. 123).
    10. "Increasing physiologic support" by following "principles of motor learning" (Duffy, 1995, p. 381).
    11. "Motor approach" relying heavily upon "principles of motor learning" (Yorkson, Beukelman, Strand, & Bell, 1999, pp. 552-553).
  11. Publications on FEEDING, DYSPHAGIA, and OROFACIAL MYOLOGY spanned the years 1978 through 2000. They were replete with a wide variety of oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques organized by:
    1. Body part (e.g., techniques to facilitate movement and position of the upper lip, lower lip, tongue tip, tongue back, tongue sides, head, neck, and so forth).
    2. Sensory and motor process (e.g., techniques to improve muscle tone, normalize tactile sensitivity, dissociate movements, stimulate reflex responses, and so forth).
    3. Eating and swallowing skill (e.g., techniques to facilitate chewing, sucking, swallowing, transferring food, creating a bolus, and so forth).
  12. Publications on FEEDING, DYSPHAGIA, and OROFACIAL MYOLOGY utilized various terms to describe these methods. For example:
    1. "Sensory stimulation to evoke movement [and] external control of involuntary, abnormal movement" (Campbell, 1978, p. 1).
    2. "Myofunctional therapy" (Garliner, 1981, p. 3)
    3. "Oral motor control exercises" (Logemann, 1983, p. 133).
    4. "Lip and facial exercises" (Groher, 1984, p. 137).
    5. "Myotherapy" (Hanson & Barrett, 1988, p. 231).
    6. "Oral motor treatment" (Arvedson & Brodsky, 1993, p. 327).
    7. "Therapeutic exercises" (Tuchman & Walter, 1994, p. 109).
    8. "Treatment strategies and activities ... for improving oral motor skills" (Morris & Klein, 2000, p. 402).
  13. Publications on PHONOLOGY contained very few specific jaw, lip, and tongue facilitation techniques. However:
    1. Most of these texts discussed a client's "stimulability" or his "readiness" for phoneme production (i.e., the client's ability to move and position the jaw, lips, and tongue correctly for production of a target phoneme given an auditory and visual model as well as a verbal description).
    2. Several discussed or recommended the use of tactile cues to facilitate correct production of phonemes.
    3. A few of these publications seemed to have confused or blended the terms "phonetics" and "phonology", essentially replacing the prior with the latter (for a brief discussion, see, Winitz, 1984, pp. xi-xiv). They contained techniques to position the jaw, lips, and tongue.
    4. One publication recognized the movement aspect of distinctive features: "Distinctive features are sets of consistent motoric gestures" (Blache, 1982, p. 62).
  14. Publications that covered BOTH ARTICULATION AND PHONOLOGY TOGETHER IN ONE VOLUME were published from 1981 through 2004. They contained information about oral motor techniques related to phoneme production; however, they also contained cautions about the use of these methods (e.g., see Bauman-Waengler, 2004, p. 225, and Bernthal & Bankson, 2004, pp. 333-335).
  15. Publications with the term "ORAL MOTOR" in the title spanned the years 1978 through 2004. They were replete with oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques. The terms "oral motor treatment" and "oral motor therapy" were used throughout these publications. When the term "exercise" was used, it was used to represent a wide variety of methods (e.g., Gangale, 1993, and Rosenfeld-Johnson, 2001).
  16. All three INTRODUCTORY speech-language-hearing TEXTBOOKS discussed oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques as one option in articulation therapy. These remarks were brief, general, and in line with the overall introductory nature of the texts.
  17. The single PARENT GUIDE contained several suggestions for oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques. These were brief, cursory, and playful.
  18. Publications in ALL TREATMENT AREAS EXCEPT PHONOLOGY contained simple methods such as "wagging the tongue". Such activities were never recommended, in any of this literature, as a direct path to phoneme production or feeding/swallowing skill. Instead, such methods were suggested to facilitate overall oral sensory processing and movement skill for later phoneme production and later or simultaneous feeding/swallowing training. These methods were recommended to:
    1. Facilitate a client's attention and orientation to the oral mechanism at a gross level.
    2. Help the client begin to move the oral mechanism in gross movement patterns.
    3. Achieve other neuromuscular ends (e.g., increase tonus, increase range of tongue motion, differentiate tongue from jaw or lip movements, facilitate midline integration of oral movement, normalize oral tactile sensitivity).
  19. NONE OF THESE PUBLICATIONS used the term "non-speech oral-motor exercises" to identify oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques.
  20. NONE OF THESE PUBLICATIONS advocated that oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) treatment be used as a replacement for any aspect of articulation or phonological therapy. In fact, the opposite is true. Every publication concerned with speech production discussed the use of these methods within a complete program of speech management, a program that includes stimulation of auditory awareness and discrimination, cognition, attention, memory, and other basic skills. None advocated that "non-speech oral motor exercises" be used instead of articulation or phonological procedures.
  21. HISTORICAL READING (starting in 1912 and reading year-by-year until 2007) revealed that the basis for understanding movement development, assessment, and disorders has become increasingly more sophisticated throughout the century.
  22. THE SAME TYPES of oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques overlapped in ALL treatment areas. Careful analysis of these procedures revealed that they could be organized into at least 22 distinctive types or "Fundamental Methods" listed here and defined later in this publication:
    1. Assist oral movements
    2. Associate oral movements
    3. Contrast oral movements
    4. Cue oral movements
    5. Describe oral movements
    6. Develop sensory awareness and discrimination for oral movements
    7. Direct oral movements
    8. Dissociate oral movements
    9. Exaggerate oral movements
    10. Increase or decrease muscle tone for oral movements
    11. Increase range of motion for oral movements
    12. Inhibit oral movements
    13. Maintain oral positions
    14. Mark the target of oral movements
    15. Model oral movements or positions
    16. Normalize tactile sensitivity for oral movements
    17. Practice oral movements
    18. Resist oral movements
    19. Speed up or slow down oral movements
    20. Stabilize oral movements
    21. Stimulate reflexive oral movements
    22. Vivify oral movements


DISCUSSION

The results of this literature review revealed that oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques have had substantial representation throughout the field of speech-language pathology from 1912 through 2007. These methods were described, discussed or recommended, in part or in whole, in 95.24% of reviewed textbooks, clinical guidebooks and conference proceedings in the areas of articulation, phonology, motor speech, feeding, dysphagia, orofacial myology, and oral motor, as well as introductory texts and one parent guide reviewed. Speech-language pathologists at all educational levels, from bachelor's level clinicians through full professors and ASHA presidents, have contributed to the discourse on methods to improve oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) skills.

The Term "Oral Motor"

Forty-three functional phrases were used to refer to oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques throughout the century. From "tongue gymnastics", in 1912, through "methods and techniques that can be used when the client cannot produce a target sound at all", in 2007, these descriptive phrases each reflected the authors' style and circumstance. The term "oral motor" did not appear in these publications until 1978, and then it was used in relation to both feeding and speech in children with neuromuscular disorders (Wilson, 1978). The term "oral motor" was used for the first time in an articulation therapy publication in 1992 (Marshalla, 1992). Both "oral motor therapy" and "oral motor treatment" seem to be two of many identifiers of these methods.

The Term "Non-speech oral-motor exercises"

The term "non-speech oral motor exercises" (NS-OME) was never used in any of these publications. This literature review did not make clear why the term NS-OME has been adopted recently by some writers (Banatoi, 2007, Lof &Watson, 2004, 2008, and Hodge & Salonka & Kollias, 2005). Perhaps "exercise" has been chosen because Van Riper used it. Van Riper has been called the "father" of traditional articulation therapy, and his basic therapy text was reprinted more than any other on the list. Van Riper used the term "exercise" to represent the wide variety of oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques he discussed. A few newer publications also used the term "exercise", and they too used the term to refer to a wide variety of methods (e.g., Rosenfeld-Johnson, 2001, 2005).

Cure-all

None of these publications suggested that oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques are a cure-all for speech production problems. Nor did any of these authors suggest that these methods be used as a replacement for traditional articulation or phonological therapy. Every publication that addressed the topic of articulation therapy clearly described the use of oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques within the context of a full program of articulation and/or phonology.

"Wagging the Tongue"

Simple methods, such as "wagging the tongue, sticking out the tongue, and puckering the lips" (Banotai, 2007, p. 8), were discovered throughout all this literature, but none of these publications recommended them as a direct path to phoneme production. Instead, non-task specific activities such as these were recommended for three basic reasons: (1) to facilitate gross oral awareness of the oral mechanism, (2) to vivify oral movements, or (3) to achieve some other neuromuscular end. For example, "wagging the tongue" was suggested to orient a client to his mouth, to help a client discover that he had a tongue, to increase tone in the tongue, to increase range of motion of the tongue, to facilitate midline integration of oral movements, and to differentiate tongue movements from lip and/or jaw movements.

A lack of organization, and perhaps a misunderstanding of purpose, intent, vocabulary, and history, seems to have lead to the current confusion between the term "non-speech oral-motor exercises" and the classic perspective of "oral motor treatment" or "oral motor therapy" represented in this literature reviewed. Somehow the view has evolved recently that oral motor treatment consists of non-task specific techniques such as "wagging the tongue". There seems to be the new belief that simplistic activities such as these have been advocated so that articulation errors, and perhaps feeding problems, will magically disappear. This relatively recent view is not congruent with what actually is written in the literature reviewed. None of the authors who wrote this extensive body of literature made such a claim. None claimed that non-specific oral motor tasks would result in phoneme correction.

The present literature review has revealed that the writers of oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques always have referenced a deep understanding of the way phonemes are produced. There has never been anything "non-speech" about these exercises. None of these publications used the term "non-speech oral-motor exercises". This suggests that the term NS-OME is unrelated to these widely published historical accounts. The term "exercise" is found by itself in these publications, but it is used in the generic sense meaning "activity", and it refers to a wide variety of facilitation techniques, from limited ones like "wagging the tongue", to far-reaching ones like those used to normalize oral tactile sensitivity or to improve muscular tone.

Disorganization

Perhaps oral motor treatment has become controversial due to the disorganized nature of some of this material. Consider the following list of techniques to stimulate the lip and facial muscles in a program of dysphagia management:

"Broad smiling ... Tight frowning ... Alternating lip pursing and retracting ... Practice producing words and sounds: u, m, b, p, w ... Resistive sucking on a pinched straw ... Blowing up cheeks with mouth tightly closed ... Blowing exercises ... Hard sucking on frozen popsicle ... Pursing lips around button tied on a string" (Asher, 1984, p. 137).

A list such as this is typical of the way this material is presented in many of the publications studied. The techniques are presented as good ideas, suggestions to try, and things that have proven useful clinically. Laundry lists like these lend themselves to random picking and choosing if there is no discussion about why to select one method over another, and if there are no controlled studies on any of them. The neurophysiological basis for the techniques often is disregarded. No controls weaken their potential application in other clinical settings.

Perspective

Another cause of confusion may stem from a lack of perspective. Many of the same methods appear in one publication after another across every treatment area throughout the entire century. However professionals who specialize in only one or two of these treatment areas might not realize that the same ideas and techniques course through all this literature. Only two authors (Marshalla, 1992, and Bahr, 2001) have taken a bird's eye view of all of these treatment areas (articulation, phonology, motor speech, feeding, dysphagia, orofacial myology, and oral motor) to discuss the overlapping nature of these methods. They have begun to gather these methods into a comprehensive whole for discussion.

Phonology

Publications that discussed phonology as a single topic contained very few recommendations for oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques. This might suggest an underlying philosophy that children who are studied for their phonological problems do not demonstrate the types of oral control problems present in clients with muscle function delay or disorder. However, tactile cueing to teach distinctive features of targets was discussed by Hodson and Paden (1983), and several other phonology publications cited their work. "The child needs to learn what the phoneme 'feels like' as well as what it sounds like. ... We use tactual cues as supplements when first presenting the new target. ... Tactual cues are simply ways in which the child can, through feeling, gain additional information about the image of the target" (Hodson & Paden, 1983, p. 59). Hodson and Paden recommended the Motokinesthetic cueing system (Young & Hawk, 1955), and they suggested, "The imaginative speech-language pathologist will devise many additions to this list [of tactual cueing techniques] when prompted by the needs of the child" (Hodson & Paden, 1983, p. 51). Clearly these authors recognize the need to help clients learn how to move and position the jaw, lips and tongue correctly for phoneme production. "We place great emphasis on cueing the child for correct production of the target pattern" (Hodson & Paden, 1983, p. 47). The authors' background in phonetics and traditional articulation therapy comes through.

Stimulability

It is also notable that a standard practice in phonology seems to be one of choosing sounds "for which the child is stimulable" (Lowe, 1994, p. 178). "If a child is stimulable, he or she produces a sound in error, but following a model of the sound the child can correctly imitate or repeat the sound" (Elbert & Gierut, 1986, p. 98). Does this not suggest that a stimulable sound is one in which the client has already gained, or is about to gain, sensory and motor control? This is an argument that has arisen in the phonology literature itself (referenced in Elbert & Gierut, 1986, p. 98). Careful analysis of any distinctive feature clearly indicates that certain movements are required to achieve that feature. For example, a phoneme can be [+Back] only if some part of the back of the oral mechanism moves. Only one phonology publication broached this topic (Blache, 1982, p. 62).

Acceptance

There seems to be little argument regarding the use of oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques in feeding, dysphagia, motor speech, and orofacial myology. These publications contain hundreds of methods to facilitate jaw, lip, and tongue function, and there has been little outcry about it despite a similar lack of research.

Articulation

Today's real argument about oral motor techniques seems to be directed toward articulation therapy (Banatoi, 2007, Lof & Watson, 2004, 2008, and Hodge & Salonka & Kollias, 2005). This relatively recent view seems to be that there is no proof that techniques to help clients move their articulators has been effective in articulation therapy. However, articulation therapy, by its very nature, is a process of adjusting jaw, lip, and tongue movement and position for phoneme production. "Speech production is a highly precise and practiced motor skill" (Kent, 1980, p. 38). "The SLP who is interested in correcting misarticulation should never lose sight of the fact that articulation is, among other things, a motor act" (Van Hattum, 1980, p. 168).

Some clients with articulation errors are able to make adjustments to jaw, lip, and tongue movement and position after simply receiving a visual and auditory model along with a verbal description - a process one might call "Show and Tell" therapy. These clients are easy to manage, and they progress swiftly. Other clients, however, move very slowly through the stages of articulation treatment, and they seem to require the use of specific tactile and proprioceptive input to achieve target jaw, lip, and tongue movements and positions. These clients cannot seem to get their jaw, lips, or tongue to move and position well enough to produce target phonemes when given only visual and auditory information. For example, consider clients in unsuccessful long-term articulation therapy for a bi-lateral lisp or a distorted /r/. These clients clearly need an articulation program that is embedded with techniques to facilitate jaw, lip, and tongue function specific to the production of their misarticulated phonemes. "The ultimate goal of articulatory intervention is to change motor performance" (Fletcher, 1992, p. 219). The historical record, written by so many authors over so many years, substantiates this claim. Articulation therapy is highly stylized movement therapy even when auditory stimulation is the main focus of the treatment.

Movement Basics Lacking

Techniques to facilitate improvements in jaw, lip and tongue function in feeding or speech therapy are, by their very nature, movement techniques. Yet speech professionals, not movement professionals, have formulated the methods reported in the speech literature. The result is that the articulation, phonology, motor speech, feeding, dysphagia, and oral motor literature contains literally hundreds of methods to facilitate oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) skills, but these techniques are not integrated into a comprehensive body of knowledge that crosses all discipline areas. Nor have many of these methods undergone the rigorous controlled study now viewed as so important.

Fundamental Methods

The recurring and overlapping nature of these techniques scattered throughout this literature suggests that there are methods of facilitating improved oral function that are fundamental to all of these treatment areas. When grouped, the oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques advocated throughout these publications can be arranged into 22 basic types. These types are discussed with examples in "Proposal" below.

Clamoring for Information

This literature review gives us perhaps some insight as to why practicing speech-language pathologists are clamoring for information about oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques for articulation therapy. That has to do with the content of articulation therapy textbooks themselves and speech-language curriculums.

Some articulation textbooks are replete with specific oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques. They contain page after page of very specific detail about facilitating the movements required for specific phonemes [e.g., Nemoy and Davis (1925), Young and Hawk (1955), Hanson (1981), and Secord et al (2007)]. Other articulation textbooks contain general discussions with sample techniques for facilitating oral movement for speech sound production [e.g., Weiss, Lillywhite & Gordon (1980), Bernthal & Bankson (2004), and Creaghead, Newman, & Secord (1989)]. Still others contain only a few ideas about facilitating oral movement, and these limited ideas are scattered here and there throughout the text [e.g., Flowers (2003)]. An individual speech-language pathology student who is being trained in these matters is exposed to the particular viewpoint of the textbook used and the personal clinical experience of the teaching or supervising professor. Some speech-language pathologists get comprehensive training in these matters, and others do not.

Despite sometimes limited training, most speech-language pathologist's have caseloads that contain clients with articulatory errors. Professional speech-language pathologists must know how to address every phoneme that might be in error because they treat clients with a wide variety of articulation errors. They need to know how to facilitate improved jaw, lip, and tongue function for phoneme production regardless of the fact that not all the data is in. Many speech-language pathologists also must provide feeding therapy, another process in which they may have received little or no training. Professional speech-language pathologists often are forced to figure these things out for themselves, and many have turned to the arena of continuing education for help. They also have looked to independent book publishers for clinical guides that contain "how to" information. Continuing education programs, and non-traditional clinical guides, offer the techniques therapists need to face the articulation and feeding problems of today's diverse populations. These seminars and books on oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques are provided by speech-language pathologists who have decades of experience in these matters. These programs and publications are filling the gaps that many articulation textbooks and university programs leave behind.

Evidence-based Practice

The drive for evidence-based practice has caused some to question the use of oral motor techniques in articulation therapy. Yet, those (Hodge, Salonka, & Kollias, 2005; Lof, & Watson, 2004 & 2008) who question these techniques have looked only at one very small aspect of oral motor treatment, the "non-speech oral motor exercise", a concept not described anywhere in the publications we reviewed. This limited view has brought about a damaging misunderstanding within the field of speech-language pathology. It has equated "non-speech oral-motor exercises" with the broad range of oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques described throughout one hundred years of speech-language pathology. It has forced many of the older, but clinically sound, techniques out of textbooks and university classes, and it has limited the introduction of new techniques that have not undergone rigorous scientific investigation. All oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques seem to have been lumped into one small category called "non-speech oral motor exercises", an idea that appears to have very little to do with the methods described in the literature studied for this extensive review. As a result, the broad range of methods that have developed throughout the century are now being treated as old-fashioned, unproven, and, in some cases, suspicious or dangerous.

However, evidence should come from the scientific laboratory and from clinical practice. Dollaghan (2007) has defined evidence-based practice as, "the conscientious, explicit, and judicious integration of 1) best available external evidence from systematic research, 2) best available evidence internal to clinical practice, and 3) best available evidence concerning the preferences of a fully informed patient" (Dollaghan, 2007, p. 2). A lack of external laboratory evidence does not mean there is a lack of internal clinical evidence. The historical record of techniques, described by the authors of the literature studied for this review, supplies us with a cornucopia of evidence internal to clinical practice. To disavow oral motor treatment completely is to discard the 100 years of internal clinical evidence that has lead practicing speech-language pathologists to where they are today. "Lack of data does not mean that we should do nothing. Using the limited data that are available, along with an analysis of the motor tasks, we can assemble thoughtful paradigms for clinical application" (Kent, 2008). We have more decades of clinical trial-and-error evidence in matters of jaw, lip, and tongue function than we have in any other aspect of speech-language pathology. Instead of throwing out these methods, we should be treasuring and further refining this information to the level of knowledge expected at this point in our profession. What we need now are clinicians and researchers willing to investigate specific techniques in controlled studies in order to begin to provide us with the external evidence we need for the future.

RESEARCH NEEDS

A number of research needs, and advice for advancing into such research, have arisen as a result of this literature review.

Movement and Articulation

Research on oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques should NOT be limited to "non-speech oral-motor exercises". Careful reading of the historical literature has revealed that there are at least 22 specific types of oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques that currently are under employment in the clinical arena (see details below). Each one of these ideas will make for an excellent series of research projects. A wide variety of questions could be asked. For example: What impact does resistance have on tongue tip, tongue back, or tongue side elevation for production of stop consonants? How does tapping the center of the tongue influence the creation of a midline groove for production of sibilants in clients with bi-lateral lisp? What impact do procedures to stabilize the jaw have on clients with a frontal lisp? How do techniques to influence oral tactile awareness and discrimination influence production of /r/ in clients who have failed in traditional therapy? Do clients with lateral lisps demonstrate differences in oral-tactile sensitivity?

Type of Stimulation

Future research projects need to be very specific about the type of stimulation methods employed, and care should be taken not to confuse methods. For example, studies should not compare methods of "cueing movements" with techniques to "stimulate oral reflexes". That would be comparing apples to oranges. Research projects should be designed to isolate individual facilitation techniques, and to compare them within and across population groups. Isolating techniques may prove to be a difficult process because often there is overlap. But studying isolated techniques will yield better data about what truly is effective in treatment.

Developmental Data on Speech Movement

Another great need within this area of study is for developmental data. Publications on feeding reported month-by-month development in oral movement skill. But the body of literature studied for this report revealed no such developmental data in regard to speech movements. We do not know, for example, when children are able to lift the tongue-tip to the alveolar ridge during production of speech. Can children elevate the tongue-tip at 12 months when using /d/ on first words? At two years after having reached the two-word stage? At ten months during babbling? At four months during cooing?

We also need to know what makes the immature production of phonemes different from mature productions. For example, the articulation literature clearly treats /l/ as a later-developing phoneme, and explains that young children produce /l/ with some distortion. We do not know, however, what a child does during his immature production of /l/ that makes it different from a mature one. Is he moving his jaw, lips, or tongue differently? If so, how? What is the immature oral movement pattern? How is it different from a mature oral movement pattern utilized in production of /l/?

Data on Incorrect Oral Movement Patterns

We also need to know what oral movements cause phoneme distortion. What oral movements make a distorted /r/ different from a correct one? What tongue movements make a bilateral /s/ different from an /s/ produced with midline air stream? What are the oral movement patterns of the client with severe speech distortion in the absence of neuromuscular disease? Fletcher's palatometer studies (1992) describe the equipment and procedures that might be used for these investigations.

Movement and Phonology

Research is also needed to investigate the underlying relationships between phonological patterns and movement, for it is at the level of distinctive features where phonetics, phonology, and oral motor converge. Many questions could be asked: What are the movements necessary to achieve each distinctive feature? What movements are necessary to make a phoneme [+Back], [+Front], [+Strident], and so forth? How do specific sensory and movement problems interfere with the acquisition of distinctive features? How does low muscle tone, for example, interfere with the production of final consonants, consonant clusters, or syllables? What percentage of clients who Back phonemes have a diagnosis of oral tactile hypersensitivity? How does low muscle tone interfere with jaw stability and the production of stridency?

PROPOSAL
twenty-two fundamental methods

It is proposed that the study of oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques will be served by analyzing existing treatment techniques from many areas, by defining vocabulary, and by sorting this material into "fundamental methods" based on sensory and movement treatment procedures, i.e., grouping according to the type of sensory and movement technique being employed, not the body part, phoneme, or feeding skill being facilitated.

The following format describing 22 Fundamental Methods is proposed. It was formulated after studying the 84 publications used for our review. Each technique is described and examples from the literature are given. It is hoped that this format will be helpful in several ways: 1) in the process of organizing the past century of clinical insights, 2) in the design of future research studies, and 3) in the planning of treatment sessions for individual clients. It is also hoped that this material will enlighten the profession about the broad scope of oral motor treatment that has been described in the articulation, phonology, motor speech, feeding, dysphagia, orofacial myology, and oral motor literature from 1912 until the present day.

1. Assist Oral Movements

To assist is to "help (someone), typically by doing a share of the work" (Jewell & Abate, 2001, p. 96). "[Manipulation] may be necessary to place the organs in the starting position for the sound to be made" (Nemoy & Davis, 1937, p. 36). Assistance can be "passive positioning or manipulation" (Hardy, 1983, p. 170), or it can be active. Active assistance requires that "the therapist, with a small degree of effort from the child, moves the body part through the desired pattern of movement" (McDonald & Chance, 1964, p. 65). Speech-language pathologists use their own hands, fingers and other tools to assist clients in their attempts to achieve specific jaw, lip, and tongue movements and positions. Techniques to assist oral movements appeared in many of our researched texts. Examples:

  • To assist tongue back elevation for /r/: "A flat stick or a small rod ... may be put under the tongue to push it back and up" (Scripture, 1912, p. 148).
  • To assist lower lip elevation for /f/: "The trainer [uses the fingers and] moves the lower lip upward until it comes in contact with the curved edge of the upper teeth" (Hawk and Young, 1955, p. 16).
  • To assist tongue tip elevation for lingua-alveolar phonemes: "Sometimes it is helpful to use a tongue depressor or a rounded stick to bring the tongue into the desired position" (Berry & Eisenson, 1956, p. 42).
  • To assist jaw movement in swallowing: "Occasionally, the clinician may assist the patient's attempts at jaw movement by placing external pressure on the mandible in the desired direction of movement ... If any pain occurs, the exercise should be discontinued" (Logemann, 1983, p. 142).
  • To assist jaw lowering for /ɑ/: "Pull down the chin with your index finger" (Kaufman, 2006, p. 14).
  • To assist correct tongue placement for /θ/: (1.) "Instruct the student, 'Please stick out your tongue.' (2.) Once the tongue is out, gently close the student's mouth. If the tongue is sticking out too far, gently push it back with a tongue depressor" (Bleile, 2006, p. 23).

2. Associate Oral Movements

To associate is to "connect (something) with something else because they occur together or one produces another" (Jewell & Abate, 2001, p. 97). Speech-language pathologists use the movements and positions of one phoneme to teach the movements and positions of other phonemes. This has been called "sound modification" (Secord et al, 2007, p. 5). It has also been called "successive approximations" and "shaping" (Bernthal & Bankson, 2004, p. 302). The client who can benefit from this method obviously must be able to achieve the target position of the first phoneme before it can be used to teach the second. "The clinician instructs the client to produce a known sound and then to adjust the articulators in certain ways as he continues to produce the known sound. Each articultory adjustment is a movement that comes closer to the position necessary for the target sound. This method is often used with non-speech sounds, such as coughing to elicit a /k/" (Secord et al, 2007, Pp. 5-6). Examples:

  • Associating tongue-back elevation for /ŋ/ with tongue tongue-back elevation for /g/: "The pupil [is] induced through imitation of /ŋ/ to prolong /ŋ/ at first and then to complete the sound with a sudden expulsion of the voice" (Nemoy & Davis, 1937, p. 116).
  • Associating lingua-alveolar position for /t/ with lingua-alveolar position for /s/: "Make [t] ... Make [t] with strong aspiration on the release ... Prolong the strongly aspirated release ... Remove the tip of the tongue slowly during the release from the alveolar ridge to make a [ts] cluster ... Prolong the [s] part of the [ts] cluster in words like oats ... Practice prolonging the last portion of the [ts] production ... Practice 'sneaking up quietly' on the [s] (delete /t/) ... Produce [s]" (Bernthal & Bankson, 2004, p. 302).
  • Associating tongue-tip protrusion for /θ/ with tongue tongue-tip elevation for /l/: "Instruct the client to say /θ/. Then tell the client to lower the jaw and draw the tongue tip backward until it contacts the alveolar ridge behind the upper teeth. While maintaining contact with the alveolar ridge, the client says /l/" (Secord et al, 2007, p. 90).

3. Contrast Oral Movements

To contrast is to "compare in such a way as to emphasize differences" (Jewell & Abate, 2001, p. 373). Speech-language pathologists help clients contrast jaw, lip and tongue positions in order to help them perceive the locations of articulatory contact. Techniques to contrast jaw, lip and tongue positions appeared in many of our researched texts. Examples:

  • Contrasting positions used to teach lip rounding for /w/: "Contrast lip spreading with lip rounding, and a large mouth opening with a small mouth opening" (Hanson, 1983, p. 206).
  • Contrasting tongue positions used to eliminate a frontal lisp: "A great way to wake up the tip of the tongue and to get the tip behind the teeth is to have the client say, 'th-s-th-s-th-s-th-s' back and forth in one continuous air stream. This practice stimulates the tip of the tongue through tactile means as it rubs forward and back against the upper central incisors" (Marshalla, 2007, p. 104).
  • Contrasting tongue tip and back positions used to learn /k/: "Have the client say /t/. The /t/ can be used to illustrate the build up of pressure and the quick release. Then have him attempt saying /t/ with the tongue tip behind the lower central incisors. Follow with the step of instructing the client to raise the back of the tongue up to the soft palate and attempt the /k/ production" (Secord et al, 2007, p. 31).

4. Cue Oral Movements

A cue is "a signal for action ... a piece of information or circumstance that aids the memory in retrieving details not recalled spontaneously ... a hint or indication about how to behave in particular circumstances" (Jewell & Abate, 2001, p. 415). Speech-language pathologists provide visual, auditory, tactile, proprioceptive and conceptual cues about oral movement and position in order to help clients learn to produce specific phonemes, and to sequence phonemes. Certain articulation programs have been based around highly stylized tactile cueing systems including: Motokinesthetics (Young and Hawk, 1953), Speech Facilitation (Vaughn & Clark, 1979) and P.R.O.M.P.T. (Chumpalik, 1984). But techniques to use some sort of cue for jaw, lip and tongue movement or position appeared, or were recommended, in almost all of our researched texts. Examples:

  • Visual and tactile cue for production of /st/: "The clinician may draw her finger up the child's bare arm while saying /s/ and tap it lightly as she releases the /t/, thus calling attention to the continuancy of /s/ and the quick burst of /t/" (Hodson & Paden, 1983, p. 51).
  • Tactile cue for lingua-velar articulation: "Pressure applied well under the child's chin, upward and toward the base of the tongue, will reinforce back-of-tongue ... productions" (Blakely, 1983, p. 30).
  • Verbal and visual cues to teach fricatives: "We had Clifford stick out his tongue and blow over the top of it to produce "th" or a close approximation of it. ... By providing additional cues regarding tongue, lip and teeth placement, fricative production can be shaped" (Mowrer, 1984, p. 96).
  • Conceptual cue (the "angry cat") for production of /f/: "Make a loose contact between the upper front incisors and the lower lip and force the air stream between them to produce frication. Do not use voice. This is the angry cat sound. Hear the cat go 'f-f-f-f'" (Flowers, 2003, p.39).
  • Hand signal cue for /m/: "Slide index finger across lips horizontally or place fingers directly over lips as in 'blowing a kiss'" (Kaufman, 2006, p. 20).

5. Describe Oral Movements

To describe is to "give an account in words of (someone or something), including all the relevant characteristics, qualities, or events" (Jewell & Abate, 2001, p. 462). "Most patients do not improve simply by talking. They often need some instruction" (Duffy, 1995, p. 382). "Both modeling and demonstration are mostly preceded or accompanied by verbal instruction" (Hegde, 1998, p. 155). The phonetic placement approach (Van Riper, 1954) is a method of describing oral movement for phoneme production. "The phonetic placement method has probably been used as long as anyone has attempted to modify speech patterns. ... [It] involves explanations and descriptions of idealized phoneme productions. The verbal explanations provided to the client include descriptions of motor gestures or movements and the appropriate points of contact (tongue, jaw, lip, velum) involved in producing the target segments" (Bernthal & Bankson, 2004, p. 301). The client "is then directed to place his articulatory mechanism in a similar position and produce a sound" (Kantner & West, 1933, p. 348). Speech-language pathologists frequently describe the movements or positions of the jaw, lips, and tongue in order to help clients achieve target phonemes and feeding skills. Descriptions of jaw, lip and tongue movements or positions appeared in almost all of our researched texts. Examples:

  • To describe lip position for /v/: "[The client] is told to bite his lower lip" (Scripture, 1912, p.124-125).
  • To describe tongue position for /t/: "Discuss how this sound is produced, including how the tongue is positioned on the alveolar ridge" (Folk, 1992, p. 6).
  • To describe tongue tip placement for lingua-alveolar phonemes: "See the tip of my tongue? I am going to make it real small like this. Then I am going to lift it up. See? Then the tip of my tongue is going to touch this part of my mouth. Did you see that? Can you do it?" (Hegde, 1998, p. 155).
  • To describe lip position for /m/: "Carefully explain the production characteristics using diagrams or illustrations if possible (e.g., pointing out to the client the lip-to-lip posturing, and pointing out that the air will escape through the nose while making the humming sound /m/)" (Secord et al, 2007, p. 74).

6. Develop Sensory Awareness and Discrimination for Oral Movements

To be aware is to have "knowledge or perception of a situation or fact" (Jewell and Abate, 2001, p. 113). To discriminate is to "recognize a distinction" and to "perceive ... the difference in or between" (Jewell & Abate, 2001, p. 488). "Tongue and lip awareness activities can often be utilized with beneficial results. They are employed ... to heighten the child's awareness of tongue and lip movements" (Bauman-Waengler, 2004, p. 225). "It could be said that without sensory input there would be no movement" (Mysak, 1980, p. 194). "Evidence accumulates that somatic feedback, particularly touch-tactile and kinesthesia-proprioception, is vital to the learning and maintenance of motor speech" (Irwin, 1972, p. 20). Speech-language pathologists utilize hands, food and other objects to help a client become more aware of the different parts of his mouth and to help him learn to discriminate different sensory parameters of oral stimuli. These activities build a firm tactile foundation for learning phonemes by place and manner, and for eating. Such activities are represented broadly throughout the literature, but are especially prominent in texts with a sensorimotor and neurodevelopmental basis. Older texts often recommended these as part of their speech "warm-up" activities. Examples:

  • To develop general oral sensory awareness: "Learn to recognize the movement as part of some familiar biological movement such as chewing, swallowing, coughing ... chew in an exaggerated fashion ... practice licking the lips and cleaning the tongue and cheeks with the tongue" (Van Riper, 1954, pp. 216-218).
  • To develop general oral sensory awareness and discrimination: "Provide many opportunities for the child to engage in generalized mouthing activities of the hands, simple environmental objects, and toys" (Morris & Klein, 2000, P. 411)
  • To develop oral sensory awareness and discrimination: "Massage is completed on both the external and internal oral structures. Intraoral massage ... can increase intraoral awareness and has the potential to improve the child's responses to sensation in the oral area" (Bahr, 2001, p. 177).
  • To develop sensory awareness of the lips: " 'Bite' the lips. First the upper and then the lower lips are 'sucked into' the slightly open rows of teeth ... 'Rub' both lips together. First right and left, then forward and backward" (Bauman-Waengler, 2004, p. 225)
  • To develop sensory awareness and discrimination of the mouth: "Slightly dampen a non-flavored Toothette ... Massage [the client's] lips using a twisting motion. While continuing the twisting motion, work into his mouth via the buccal cavity on both sides. Progress to the surface and lateral margins of his tongue" (Rosenfeld-Johnson, 2005, p. 146).

7. Direct Oral Movements

To direct means to "aim (something) in a particular direction" (Jewell and Abate, 2001, p. 483). Speech-language pathologists direct jaw, lip and tongue movements, as well as phonation and airflow, with their own arms, hands, fingers and other instruments, and with ideas. "Gestural cues ... can provide additional information for the client" (Yorkson, Beukelman, Strand and Bell, 1999, p. 554). Activities to direct oral movement or airflow were mentioned in approximately half the literature reviewed. Examples:

  • To direct air stream for /s/: "Have the patient practice emitting expired breath streams thru [the] small hole ... of a hollow, rubber tube" (Borden & Busse, 1929, p. 184).
  • To direct tongue tip elevation to the alveolar ridge for production of /l/: "Place thumb and middle finger in a flattened position on upper lip points 2. Press evenly while phonating" (Vaughn & Clark, 1979, p. 200).
  • To direct tongue elevation for /ɚ/: "Tell the client you are going to pull on an imaginary string attached to the back of his head. As you pull the imaginary string up from the back of the client's head, instruct the client to lift the back of a tensed tongue and say /ɚ/" (Secord et al, 2007, p. 153).

8. Dissociate Oral Movements

To dissociate means to "disconnect or separate" (Jewell & Abate, 2001, p. 494). "The ability to dissociate one movement from another and separate the movement of different parts of the body, is necessary in the developmental progression toward refinement of gross and fine motor skills" (Morris & Klein, 2000, p. 63). "Of particular importance in articulating is the ability to disassociate movements of the tongue from movements of the mandible or lips" (McDonald & Chance, 1964, p. 124). "When dissociation and grading have not developed, compensatory postures or fixing occurs ... [This] inhibits mobility and thus reduces skill levels for both feeding and speech clarity" (Rosenfeld-Johnson, 2005, p. 7). Speech-language pathologists help clients dissociate between movements of the jaw, lips and tongue so that appropriate movements can be made for phoneme production and feeding skills. Techniques to dissociate jaw, lip and tongue movements appeared in many of our researched texts. Examples:

  • To dissociate tongue movement from jaw movement for /t/: "The insertion of the broad side of a tongue depressor between the side teeth and holding it steady while repeating t, t, t, in rapid succession will assist in securing independent action of the tongue" (Nemoy & Davis, 1937, p. 90).
  • To dissociate tongue tip from lip movement in production of /l/: "Retract the lips sharply, holding them back with the fingers if necessary, and ask the child to sing 'la-la-la'" (Berry & Eisenson, 1956, p. 151).
  • To dissociate tongue movement from lip movement for /r/: "The lip retractor is a device designed for use by orthodontists for photographing the teeth. Placed correctly in the mouth, the lip retractor pulls the lips laterally. With the lip retractor in place, most clients will be unable to move the lips at all. This is a great way to help them focus on what their tongues should be doing" (Marshalla, 2004, p. 113).

9. Exaggerate Oral Movements

To exaggerate is to "represent (something) as being larger, greater, better, or worse than it really is" (Jewell & Abate, 2001, p. 590). Speech-language pathologists often exaggerate jaw, lip and tongue movements to make them salient for the client. Exaggeration of oral movement also is required of the client himself in order to help him understand his own oral movements, and to make his or her oral movements more precise. Recommendations to exaggerate oral movements appeared in a wide variety of texts. Examples:

  • To exaggerate as a general articulation method: "When the correct sound has been produced ... the [client] should hold it, increasing its intensity, repeating it, whispering it, exaggerating it, and varying it in as many ways as possible without losing its identity. He should focus his attention on the 'feel' of the position in terms of tongue, palate, jaws, lips, and throat" (Van Riper, 1954, p. 239).
  • To exaggerate in order to understand incorrect movements: "Encouraging exaggeration of the undesirable movement will make it more obvious to the child" (McDonald & Chance, 1964, p. 124).
  • To exaggerate between oral position for /m/ and vowels in simple CV syllables: "Exaggerate the contrast between lips tightly closed and widely parted on /mah/, /maw/, and /mo/. Sustain the closed portion for a couple of seconds before opening the mouth" (Hanson, 1983, p. 201).
  • To exaggerate overall precision of articulation: "When a [dysarthric] patient's articulatory movements are imprecise, he or she may be taught to exaggerate them, making them more precise" (Brookshire, 1992, p. 264-265).

10. Increase or Decrease Muscle Tone for Oral Movements

Muscular tone is "the degree of stiffness" in the musculature "to stabilize or move the skeleton" against gravity (Boehme, 1990, p. 210). "Even a relaxed muscle has a residual low-level turgor or feeling of firmness" (Rasch & Burke, 1978, p. 48) referred to as its tone. Tone can be too high (hypertonic) or too low (hypotonic): (1) Hypertonic muscles are hyper functional and in a state of excess or continual contraction. Hypertonic muscles cause body parts to move stiffly and in a jerky fashion. When severe, hypertonicity can cause body part immobility. (2) Hypotonic, or lax muscles, on the other hand, are slower and weaker in their contraction, and they tend to lack endurance for sustained contraction. Hypotonicity also can cause body part immobility when it is severe.

Speech-language pathologists use techniques to increase or decrease muscle tone in order to encourage more mature jaw, lip and tongue movement patterns for speech and feeding. "Stroking, tapping, kneading, rocking, bouncing, slapping, shaking, stretching, and compressing techniques may all be used to influence the type of muscle tone displayed by the child" (Mysak, 1980, p. 243). Oral muscles can be considered light-work muscles. "Muscles may be activated by stroking the skin area over the belly of the muscle or the area over its insertion. Brushing activates light-work muscles" (McDonald & Chance, 1964, p. 70). Older textbooks on articulation therapy that were published in the first half of the century tended to report general relaxation techniques to reduce tone, and they recommended drill-like exercises to increase tone. Newer texts that dealt with the neuromuscular and sensorimotor bases of articulation or feeding disorder described techniques to increase or decrease muscular tone using methods of physical manipulation. Examples:

  • To decrease muscle tone in the tongue for production of lingua phonemes: "Request the patient to protrude the tongue so that it can be grasped gently. Next, pull it forward as completely as possible ... Once fully withdrawn the tongue is slowly pulled to the right corner of the mouth, held there for an out-loud count of 10 seconds, and then smoothly moved across the midline to the left corner of another count of 10 seconds to complete the trial. Although the degree of hypertonicity present will probably produce resistance to these adjustments, maintaining the lateral pulling force along the way usually proves fruitful after 10 or 15 trials with most patients" (Dworkin, 1991, p. 197).
  • To increase muscle tone in the tongue: "Suction tongue against 'roof' of mouth, as if ready to 'pop.' Keep whole tongue tight against top and pull chin down ... Never [move the] tongue off the top. Repeat 5 times. This exercise can be difficult. If tongue falls [from] the top of the mouth, try again" (Czesak-Duffy, 1993, p. 28).
  • To decrease muscle tone in the facial muscles: "Use facial molding ... begin with a general massage of the child's body and face ... gently mold or massage the face toward a closed mouth/closed lip position" (Morris & Klein, 2000, p. 415).

11. Increase Range of Motion for Oral Movements

Range is "the area of variation between upper and lower limits on a particular scale" (Jewell & Abate, 2001, p. 1409). Range of motion, as it relates to bodily movement, refers to the extent to which the body can flex and extend, lateralize left and right, and rotate around its axes. The full range of oral movement is explored in infancy and early childhood during feeding, mouthing and vocal play. A child and an adult can extend the jaw, lips, and tongue to their full range. But a child must learn to move his articulators inside this full range in order to achieve the refined jaw, lip, and tongue movements necessary for mature speech sound production. Moving within a full range of movement is known as grading movement. In the older articulation literature, "range" was called "flexibility of the articulators" (Berry & Eisenson, 1956, p. 139).

The process of learning the full range of oral movement during childhood can be hampered by several factors including muscle tone disturbance. In general, hypertonicity restricts range because of stiffness, while hypotonicity restricts range because of weakness. This is true of adults with motor speech disorders, too. For example, spastic dysarthria is characterized by "four major abnormalities of muscular function: spasticity, weakness, limitation of range, and slowness of movement" (Darley, Aronson & Brown, 1975, p. 131). Limited range also is seen in adult patients with low tone. "The salient feature of hypokinetic disorders is marked limitation of range of movement" (p. 177). Speech-language pathologists utilize techniques to help clients increase range of jaw, lip, and tongue movement so that appropriately graded oral movements can be achieved over time. Examples:

  • To increase range of jaw, lip and tongue movements for speech: "Have the patient perform lip, tongue, lower jaw ... exercises calculated to give these organs increased flexibility and hence greater capacity to adjust themselves in new positions" (Borden & Busse, 1929, p. 182).
  • To increase range of face, lip and jaw movements in speech warm-up activities: "Imitate the faces of clowns by retracting the lips, protruding the lips, and by dropping the jaw as far down as possible while producing [vowels]" (Berry & Eisenson, 1956, p. 139).
  • To increase range of motion in the tongue for eating and swallowing: "The patient should be asked to open his or her mouth as wide as possible, hold it there for 1 second, and release it. Then the patient should elevate the back of the tongue as far as possible, hold it there for 1 second, and release it. This procedure should continue with the patient stretching the tongue to each side as far as possible, extending the tongue out of his or her mouth as far as possible, and pulling it back as far as possible, holding it for 1 second in each direction" (Logemann, 1983, p. 133).

12. Inhibit Oral Movements

To inhibit means to "slow down or prevent (a process, reaction, or function)" (Jewell & Abate, 2001, p. 873). "To inhibit a response means to decrease the strength of the response or to stop the response from occurring" (Bahr, 2001, p. 91). Inhibition and facilitation techniques are basic to neurodevelopmental treatment (NDT) (Langley and Thomas, 1991, p. 1). NDT is a motor therapy with many goals including: "To inhibit primitive reflexes, abnormal postures, and abnormal movement patterns or compensatory movements" (Langley & Thomas, 1991, p. 18). Speech-language pathologists inhibit unwanted oral movements so that those required for specific phonemes and feeding skills can be facilitated. Techniques are employed to prevent habitual, reflexive, tone-based, or undifferentiated movement patterns from overriding the client's attempts at new movement. Methods to inhibit or prevent specific jaw, lip and tongue movements appeared in many of our researched texts. Examples:

  • To inhibit lip rounding for /l/: Place a small piece of Scotch tape. Vertically, at the corners of the mouth, with the lips slightly retracted. When the lips begin to move toward the /w/ position, the pulling of the tape signals the speaker that the unwanted movement is occurring" (Hanson, 1983, p. 214).
  • To inhibit tongue humping or bunching in order to encourage more tongue movement: "Treatment approaches ... often include downward bouncing or patting on the tongue ... The tongue can be stroked to obtain a central grooving or a lateral upward movement ... Brushing the center of the tongue can facilitate flattening and a more central groove" (Morris & Klein, 2000, p. 607).
  • To inhibit tip elevation during production of /k/: "Using a tongue depressor, hold the tongue tip down behind the lower teeth to hinder the elevation of the tongue tip" (Secord et al, 2007, p. 30).

13. Maintain Oral Positions

To maintain is to "cause or enable (a condition or state of affairs) to continue" (Jewell & Abate, 2001, p. 1030). To maintain an oral posture is to hit and hold a posture for increasing lengths of time. Speech-language pathologists encourage clients to maintain oral positions in order to increase awareness, voluntary control, strength and skill of positions. Maintaining oral position was scattered throughout much of the researched literature. Examples:

  • To maintain lip-to-lip articulation for swallowing: "Once the patient is able to obtain lip closure, but has not habituated it, a graduated increase in the time required to maintain closure should be used. The patient may be asked to hold lip closure for 1 minute. This should be repeated 10 times per day" (Logemann, 1983, pp. 145-146).
  • To encourage lip-to-lip articulation for /p/: "Have the child pull the upper lip (using the lip muscles, not the finger) down over the upper teeth, with the mouth open, and hold for ten seconds" (Hanson, 1983, p. 201).
  • To maintain positions for consonants and vowels: "Another speech-motor training program is the Monitoring Articulatory Postures (MAP) ... The program is in 3 phases. Phase I, Articulatory Posture Training, intends to teach the child to establish and to maintain vowel and consonant associated postures" (Jaffe, 1984, p. 178).
  • To maintain tongue tip elevation to the alveolar ridge: "Hold tip of tongue to the spot for at least 5 seconds, or as long as possible. Increase time to 30 seconds, continuing to press tip into the spot" (Gangale, 1993, p. 103).

14. Mark the Target of Oral Movements

To mark the target of oral movement means to indicate, through tactile means, the place where articulation should be made. Speech-language pathologists often use fingers or other tools to touch the place where articulation should occur. "Occasionally it is necessary only for the therapist to touch the articulatory organs at the point of contact" (Berry & Eisenson, 1956, p. 164). "The speech pathologist may touch the part of the child's tongue that he wants to contact a certain place on the roof of the mouth, then touch that part of the palate or velum to demonstrate the nature of the desired articulation" (Hanson, 1983, p. 148). "Identify contacts by stroking or pressure" (Van Riper, 1954, p. 217). "Touch cues draw attention to an aspect of a sound's production, typically the place of production" (Bleile, 2006, p. 8). "In the advanced levels of sensory assistance, the clinician concerned with speech production will find that light touching of a specific target on the palate followed by a touching of the tongue tip will help orient the tongue contact for the specific sound desired" (Nelson & Benabib, 1991, p.157). Marking a target is a form of tactile cueing. "While tactile cues outside the mouth are a part of the motokinesthetic approach, the speech-language pathologist can also give tactile stimulus inside the mouth with a tongue blade or applicator" (Bosley, 1981, p. 11). Examples:

  • To mark the lateral portions of the palate for production of /s/: Use "two knotted dental floss guides placed between maxillary lateral incisors and cuspids" (Vaughn & Clark, 1979, p. 183).
  • To mark the "spot" for tip-to-alveolar contact for correct oral rest posture: "At times we press against the spot with the end of a tongue depressor, then ask the patient to do the same. The parent watches closely, and may be asked to touch the child's 'spot' with a tongue depressor" (Hanson & Barrett, 1988, p. 275).
  • To mark the soft palate for production of /k/: "Rub a moist cotton swab on a flavored food, such as a Lifesaver ... Then touch the soft palate near the second molars with the swab and ask the client to raise the back of the tongue to the roof of the mouth to form a seal" (Secord et al, 2007, pp. 30-31).

15. Model Oral Movements

A model is "a system or thing used as an example to follow or imitate" (Jewell & Abate, 2001, p. 1096). A model is a physical representation of the desired movement or position. "The clinician uses speech production demonstrations as stimuli to induce images of desired articulatory actions, increase understanding of action sequences, and shape changes in the subject's articulatory skills" (Fletcher, 1992, pp. 220-221) Speech-language pathologists model jaw, lip and tongue movements and positions for phoneme production and feeding skills. Live models are made with the therapist's mouth. The hands also can be used to model movement and position. "One can often use the hands to demonstrate movements of the tongue relative to the palate. Let one hand represent the palate and the other the tongue ... Then move the hand representing the tongue up or down as indicated" (Bosley, 1981, p. 13). Other three-dimensional models and pictures can be used as well. Clients are expected to imitate the required jaw, lip and tongue position from the visual information provided by the model. "We recommend that that the clinician attempt to elicit responses through imitation as an initial instructional method for production training. Usually the clinician presents several auditory models of the desired behavior (typically a sound in isolation, syllables, or words), instructs the client to watch his or her mouth and listen to the sound that is being said, and then asks the client to repeat the target behavior" (Bernthal & Bankson, 2004, p. 300). Techniques to model jaw, lip and tongue movements and positions appeared in almost all of our researched texts. Examples:

  • To model oral positions with apraxic patients: "Ordinarily, therapy is best conducted with the clinician and patient seated in front of a large mirror so the patient can watch both the clinician's face as he speaks and his own face as he imitates the clinician's model" (Darley, Aronson & Brown, 1975, p. 282).
  • To model lip position for /m/: "Exaggerate the degree of inter labial contact and have the child imitate you" (Hanson, 1983, p. 200).
  • To model tongue tip to the alveolar ridge for /t/: "Use hand gestures to demonstrate how to tap the tongue against the alveolar ridge" (Secord et al, 2007, p. 23).

16. Normalize Oral Tactile Sensitivity for Oral Movements

To normalize is to "bring or return to a normal condition or state" (Jewell & Abate, 2001, p. 1167). Tactile refers to the sensation of touch perceived through nerve endings in cutaneous tissue (skin). The lips, tongue, and palate contain very sensitive and highly discriminating cutaneous tissue. To normalize oral tactile sensitivity means to help a client accept, perceive and discriminate oral-tactile experiences in, on and around the mouth. "In order to move his speech organs correctly he must feel their movements" (Scripture, 1912, p. 122) "The various parts of the mouth need to relate to one another at a sensory level to coordinate their function" (Nelson & De Benabib, 1991, p. 137). Accurate oral movement is possible when the oral tactile system functions the way it should. Speech-language pathologists provide techniques to normalize oral-tactile sensitivity so that bi-labial, labio-dental, lingua-dental, lingua-alveolar, lingua-palatal and lingua-velar contact can be explored, utilized and habituated in phoneme production and feeding skills. Techniques to normalize oral tactile sensitivity appeared in a few early texts. Most examples were found in more recent texts that dealt with the neuromuscular and sensorimotor bases of articulation, feeding and motor speech disorders. Examples:

  • To normalize the hyper functional gag reflex that interferes with articulatory movement: "To lessen such sensitivity in these patients ... the technique of maintained touch or pressure may be helpful" (Dworkin, 1991, p. 104).
  • To normalize sensitivity of the palate for lingua-alveolar, lingua-palatal and lingua-velar articulation: "We need to introduce touch to the front half of the palate, gradually moving back along the sides where the palate borders with the upper teeth. In the extremely sensitive mouth ... the clinician will find it helpful to return to working on the cheeks and activating the tongue so that the individual will alter his or her own sensitivity level with spontaneous movement. We can gradually reach a tolerance for sustained touch on the forward half of the palate" (Nelson & Benabib, 1991, pp. 156-157).
  • To normalize oral tactile hypersensitivity for overall oral movement in speech and feeding: "If the child demonstrates atypical oral motor patterns, such as a hyper responsive gag reflex or tonic bite reaction, massage can be used to bring about an improved response" (Bahr, 2001, p. 115).

17. Practice Oral Movements

To practice is to "perform (an activity) or exercise (a skill) repeatedly or regularly in order to improve or maintain one's proficiency" (Jewell & Abate, 2001, p. 1339). To practice is to rehearse, repeat, exercise, or drill. "The key ingredient in the typical skill-learning paradigm ... is practice" (Ruscello, 1984, p. 146). Speech-language pathologists often require clients to practice specific jaw, lip or tongue movements in order to improve grading, dissociation, or direction of movement for phoneme production or feeding behavior. In a motor-skills approach, "Practice is the key variable thought necessary for mastery of any skilled motor behavior ... Initially there is a sluggishness in the execution of motor skills because the learner is acquiring the movement. With practice, the motor skill is perfected and stabilized. Ultimately, the skill becomes a part of the learner's repertoire of skilled movements and becomes automatic for the speaker" (Bernthal & Bankson, 2004, p. 295). "Corrected [oral motor] patterns are strengthened by intensive practice of carefully structured assignments" (Hanson & Barrett, 1988, p. 274). Speech-language pathologists use practice to: (1) habituate oral movements, (2) improve muscular strength and endurance for performance of an oral movement, (3) improve motor memory of a performed oral movement, (4) increase volitional control over oral movements, and (5) to make new oral movements automatic. The recommendation to practice jaw, lip and tongue movements appeared in most of our researched texts. Examples:

  • To practice tongue tip elevation for /l/: "Give tongue-lifting and tongue-lowering exercises, first in silence, then while blowing, then while whispering ah, then while saying ah. Gradually lift the tongue [tip] higher and higher until it finally makes contact at the right place" (Van Riper, 1954, p. 242).
  • To practice tongue tip elevation for lingua-alveolar phonemes: "Set the metronome to 30 [beats per minute], and instruct [the client] that the task is to raise and lower the tongue-tip alternately to the respective alveolar ridges according to the beat" (Dworkin, 1991, p. 223).
  • To practice lip movements: "Pucker the lips, then relax; repeat ... Spread the lips, then relax; repeat ... Round the lips in a wide O, relax; repeat" (Bauman-Waengler, 2004, p. 225).
  • For parents to practice lip movements with their children: "Blow bubbles ... Blow kisses ... Blow whistles or party favors ... Blow on a pinwheel ... Hum your favorite song together" (Dougherty, 2005, p. 89).

18. Resist Oral Movements

To resist is to "withstand the action or effect of" (Jewell & Abate, 2001, p.1449). "Resistance increases the response of muscles in voluntary action" (Mysak, 1980, p. 149). Resistance may "increase the active range of motion [and] guide voluntary motion" (Mysak, 1980, p. 149). "There is ... a slight tendency for the articulators to respond ... to contrary direction techniques, and these can be used to assist the client [with oral movement]" (Bosley, 1981, p. 12). "Muscles exercised repeatedly against low resistance with numerous contractions will improve endurance" (Love, 1992, p. 152). "Resistance to a movement is achieved by the therapist who applies counter pressure against the surface toward which the motion is made" (McDonald & Chance, 1964, p. 72). "Isometric exercise involves exertion against stationary resistance" (Duffy, 1995, p. 384). Speech-language pathologists resist jaw, lip and tongue movements in order to develop new movements and to facilitate improved movement of these parts. Resistance techniques were found in a wide variety of textbooks. Examples:

  • Use of resistance to facilitate lip protrusion: "[Have the client] retract the lips for e [i]; as the therapist holds them back, [the client should] force the lips into protrusion" (Berry & Eisenson, 1956, p. 139).
  • Use of resistance to increase masseter strength: "The patient is asked to bite the posterior teeth together while counting to ten and forcing the masseter muscle to activate ... the forced activation of the masseter muscle strengthens it as the muscle adapts to the stress of biting action" (Garliner, 1981, p. 37).
  • Use of resistance to facilitate lateral tongue elevation for /s/: "If the elevation is difficult, have him work on lifting the sides of the tongue against resistance. This resistance can be supplied by a pair of swab sticks pushing downward on the sides of the tongue" (Hanson, 1983, p, 228).
  • Use of resistance to improve lip function using a quarter-sized button: "Loop the string through two buttonholes and tie a knot at the end. After instructing the patient to close the teeth, position the button against the teeth behind the midline of the lips ... In a tug-of-war fashion, pull on the string with moderate force as the patient is required to resist this effort to dislodge the button by vigorously contracting the circumoral musculature" (Dworkin, 1991, p. 213).
  • Use of resistance to strengthen tongue-tip extension: "Stick out the tongue as far as possible, keeping it hard and straight. ... place horizontal length of [tooth] brush against tip. Push against tongue, keeping the tongue hard and unmoving" (Czesak-Duffy, 1993, p. 46).

19. Speed Up or Slow Down Oral Movements

Speed refers to the "rapidity of movement or action" (Jewell & Abate, 2001, p. 1639). "The fundamental speed of speech movement is the most rapid of any movement in the body" (Nelson & De Benabib, 1991, p. 135). Many clients "do not move with the speed and precision demanded by good speech ... When poor muscle co-ordination is an important factor in producing the articulatory errors, we devote part of our therapy to improving the speed and precision of the articulatory musculature" (Van Riper, 1954, p. 216). Speed of oral movement is addressed in therapy with clients who lose precision of movement as they approach the normal articulatory rate involved in connected speech. Examples:

  • To increase speed of oral movement: "Chew in an exaggerated fashion ... Do this to a simple rhythm tapped out by the teacher, very slowly at first, then increasing speed" (Van Riper, 1954, p. 217).
  • Adjusting speed of oral movement in the treatment of apraxia: "Slowing the rate gives the individual more time to process sensory information ... The speaker has more time to 'feel' the movement ... Varying the rate can be an effective tool during repetitive practice of targeted utterances. This will facilitate habituation of articulatory movement" (Yorkson, Beukelman, Strand & Bell, 1999, p. 552).
  • To improve rate and rhythm of chewing: "Increase the timing and coordination of the chewing pattern ... Encourage rhythmic activities during chewing ... Many children will stomp their feet spontaneously or kick rhythmically as they are chewing" (Morris & Klein, 2000, p. 481).

20. Stabilize Oral Movements

To stabilize is "to make or become stable" (Jewell & Abate, 2001, p. 1656) or "not likely to change" (p. 1656). Stability is a fundamental concept in motor therapy. "We must have a stable base from which to develop movement and functional skills. Without that stability, our function or mobility is less controlled [and may be] impossible" (Morris & Klein, 2000, p. 62). There is an inter play of stability and mobility in all movement. Stability does not mean rigid or fixed, however. Stability is relative and dynamic: one part of the body holds relatively still so that another part can move with greater accurately. The body stabilizes proximally while moving distally. "Generally, the central or proximal parts of the body are the first to develop stability or become controlled. From a controlled, proximal base of stability, the infant can have the possibility of greater mobility and more refined distal control" (Morris & Klein, 2000, p. 62). "Postural control of a part of the body always precedes movement control of that part" (Mysak, 1980, p. 105).

Speech-language pathologists utilize techniques to stabilize the jaw for improved lip and tongue mobility. "The ability to stabilize the jaw creates the needed prerequisite for the development of skilled and refined tongue and lip movements" (Morris & Klein, 2000, p. 63). Techniques to stabilize the cheeks and face are used to improve lip mobility. Techniques to stabilize the back lateral margins of the tongue are used in order to facilitate improved mobility of other parts of the tongue. And techniques to stabilize the hip and should girdle, and the head and neck, also are incorporated in order to facilitate improved jaw mobility. "The emergence of stability and mobility functions is an essential part of speech skill development" (Fletcher, 1992, p. 13). Techniques to facilitate oral stability are found in a variety of texts. Examples:

  • To stabilize the jaw for improved tongue mobility for production of lingua phonemes: "Using a bite block to stabilize the mandible and reduce mandibular support during speech may help to increase independent lingual movement and result in improved oral articulation for speech ... [The] bite block is placed between the first molars on one or both sides ... With the block in place and following a period in which the child adjusts to the presence of the block, a series of speech sounds and sound sequences are presented for imitation by the child" (Crary, 1993, p. 224).
  • To stabilize the lips and facial muscles with low muscle tone: "Play patty-cake, peek-a-boo, and other children's games that incorporate patting, tapping, stroking, and other types of tactile and proprioceptive stimulation of the cheeks and lips. Tapping can be done directly around the temporomandibular joint to provide better jaw stability for lip and cheek mobility" (Morris & Klein, 2000, p. 445).
  • To stabilize the back of the tongue for eliminating a frontal lisp: "We can help our clients keep the tongue inside the mouth by developing [the tongue's] back lateral stability" (Marshalla, 2007, p. 115). Techniques include: "draw a picture," "stroke the zones," "smile," "bite gently on the zones," "establish the butterfly position," "hold the butterfly position," and "spread the back of the tongue" (p. 115-116).

21. Stimulate Reflexive Oral Movements

A reflexive action is "a response of some peripheral organ to stimulation of the sensory branch of a reflex arc, the action occurring immediately, without the aid of the will or without even entering consciousness" (Osol, 1973, p. 669). "Voluntary neuromuscular response may be facilitated through the use of reflex excitation ... The procedure involves the simultaneous stimulation of the reflex and the voluntary motion in the same muscle group" (Mysak, 1980, p. 150). "Muscles may be activated by stroking the skin area over the belly of the muscle or the area over its insertion" (McDonald & Chance, 1964, p. 70). Speech-language pathologists use reflex stimulation to facilitate jaw, lip and tongue movement for phoneme production and feeding skill development. Techniques to stimulate reflexive oral movement appeared only in textbooks with a sensory and motor focus. Examples:

  • To stimulate tongue cupping: "The purpose of this exercise is to stimulate the involuntary reflex, similar to the grasp reflex, that depresses the middle portion of the tongue in response to a stimulus. ... Tap the middle of the tongue with a tongue depressor ... Continue tapping long enough to demonstrate the proper procedure, then have the patient do so. This is to be continued during each of the three practices each day for one minute" (Hanson & Barrett, 1988, pp. 278-279).
  • To stimulate elevation of the tongue's lateral margins: "Touching or stroking a baby's tongue elicits a spoon-shaped lingual configuration, characterized by an upraised ridge around its outer border ... a similar posture could be elicited in adulthood by repeatedly touching, lightly stroking, or directing a stream of air across the tongue" (Fletcher, 1992, pp. 10-11).
  • To stimulate elevation of the back of the tongue for lingua-velar phonemes: "Back elevation can be facilitated by stimulating the Tongue Retraction Response (TRR). ... Stroke down the middle of the tongue to about half way toward the back ... The whole tongue humps up and back into a ball shape which completely fills the posterior oral cavity and occludes the airway" (Marshalla, 1992, p. 98).

22. Vivify Gross Oral Movements

To vivify is to "enlighten or animate" (Jewell & Abate, 2001, p. 1889). Some clients do not recognize the possibilities of their own oral movements. "Many individuals have difficulty in realizing how great a repertoire of tongue movements they possess ... Too many articulation cases have only one or two stereotyped tongue movements in their speech repertoire ... They need to learn how adaptable the tongue really is" (Van Riper, 1954, p. 238-239). "The chief enemies of clear articulation are a tight jaw, lazy tongue, and immobile lips ... A large part of [this] re-education is kinesthetic: the child becomes aware, often for the first time, of what it feels like to open his mouth ... to use his lips vigorously ... and to perform certain important movements with his tongue" (Anderson, 1953, p.158). Speech-language pathologists use hands, fingers and other objects to vivify jaw, lip and tongue movement for feeding and speech. Stetson said, "Be alert to ... chance success with the movement; nail it for the patient right then and there" (Hartson, 1988, p. 5). Techniques to vivify oral movement were found in a wide variety of textbooks. Examples:

  • To vivify general oral movement: "If these [phonetic placement] devices and instruments have any real value, it seems to be that of vivifying the movements of the tongue, and of providing a large number of varying tongue positions, from which the correct one may finally emerge" (Van Riper, 1954, p. 238).
  • To facilitate gross movement of the tongue: "Chew gum, rolling it to the side, 'plaster' it against the palate, slowly move the gum back over the palate, etc. Attempt to feel the tongue position with each movement" (Berry & Eisenson, 1956, p. 139).
  • To vivify gross oral movement for speech rehabilitation: "In instances of severe involvement ... movement may be so limited that differentiation of the various vowels and consonants is next to impossible. One can try in such a case to help the patient concentrate his energy first on activities preliminary to speech production ... The intent is to help the patient regain some concept of where his articulators are and where he must put them" (Darley, Aronson & Brown, 1975, p. 273-274).

SUMMARY

Eighty-four textbooks on articulation, phonology, motor speech, feeding, dysphagia, orofacial myology, and oral motor, as well as introduction to speech-language-hearing sciences and one parent guidebook, published from 1912 through 2007, were reviewed for their oral (jaw, lip, tongue) motor (sensory, movement, and positioning) techniques. It was discovered that these methods have had a prominent role in the speech-language-hearing profession, and that professionals of the highest rank have written about and advocated these methods. These methods were identified by at least 42 functional phrases throughout this century, from "tongue gymnastics", in 1912, through "methods and techniques that can be used when the client cannot produce a target sound at all", in 2007. These classic publications did not use, nor do they appear related to, the term "non-speech oral motor exercises". The writers of oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques have relied upon a deep understanding of the way phonemes are produced. The term "exercise" meaning "activity" was used to refer to at least 22 "fundamental methods" of oral motor facilitation when these methods were viewed from a sensory and motor perspective. Although identical methods course through each of the treatment areas studied, there have been only two attempts to take a broad overview of this material. This article has proposed a framework to organize these methods based upon basic parameters of sensory and movement skill. This literature review revealed a cornucopia of techniques that satisfy the need for trial-and-error internal clinical evidence. Suggestions for future controlled studies to provide external evidence were made.

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  52. Lof, G. L., & Watson, M. (2008). A nationwide survey of non-speech oral motor exercise use: Implications for evidence-based practice. Language, Speech, and Hearing Services in the Schools (in press).
  53. Logemann, J. A. (1983) Evaluation and treatment of swallowing disorders. San Diego: College-Hill.
  54. Love, R. J. (1992) Childhood motor speech disability. New York: Merrill.
  55. Lowe, R. J. (1994) Phonology: Assessment and intervention applications in speech pathology. Baltimore: Williams & Wilkins.
  56. Marshalla, P. J. (2007). Frontal lisp, lateral lisp: Articulation and oral-motor procedures for diagnosis and treatment. Mill Creek, WA: Marshalla Speech and Language.
  57. Marshalla, P. J. (2004). Successful R therapy: Take your oral-motor and articulation therapy to new heights. Mill Creek, WA: Marshalla Speech and Language.
  58. Marshalla, P. J. (1992). Oral motor techniques in articulation and phonological therapy. Seattle: Innovative Concepts.
  59. McDonald, E. T., & Chance, B. (1964) Cerebral palsy. Englewood Cliffs: Prentice-Hall.
  60. Morris, S. E., & Klein, M. D. (2000). Pre-feeding skills: A comprehensive resource for mealtime development, 2nd addition. Austin: Pro-Ed.
  61. Mowrer, D. (1984) Correcting multiple misarticulations. In Treating articulation disorders: For clinicians by clinicians. Winitz, H. (Ed.) Baltimore: University Park Press. (Pp. 91-103).
  62. Mysak, E. D. (1980). Neurospeech therapy for the cerebral palsied: A neuroevolutional approach, 3rd edition. New York: Teachers College Press.
  63. Nelson, C. A., & De Benabib, R. M. (1991). Sensory preparation of the oral-motor area. In Neurodevelopmental strategies for managing communication disorders in children with severe motor dysfunction. Langley, M. B., & Lombardino, L. J. (Eds.) (Pp. 131-158) Austin: Pro-Ed.
  64. Nemoy, E. M., & Davis, S. F. (1954, 1937). The correction of defective consonant sounds. Magnolia, MA: Expression.
  65. Newman, P. W., & Creaghead, N. A., & Second, W. (1985) Assessment and remediation of articulatory and phonological disorders. Columbus: Charles E. Merrill.
  66. Osol, A. (1973). Blakiston's pocket medical dictionary, 3rd edition. New York: McGraw-Hill.
  67. Rasch, P. J., & Burke, R. K. (1978). Kinesiology and applied anatomy: The science of human movement. Philadelphia: Lea & Febiger.
  68. Rosenfeld-Johnson, S. (2001) Oral-motor exercises for speech clarity. Tucson: Talk Tools.
  69. Rosenfeld-Johnson, S. (2005) Assessment and treatment of the jaw. Tucson: Talk Tools.
  70. Ruscello, D. M. (1984) "Motor learning as a model for articulation instruction." In Speech disorders in children: Recent advances. J. Costello (Ed.) (Pp. 129-156) San Diego: College-Hill.
  71. Scripture, E. W. (1912). Stuttering and lisping. New York: MacMillan.
  72. Secord, W. A., & Boyce, S. E., & Donohue, J. S., & Fox, R. A., & Shine, R. E. (2007). Eliciting sounds: Techniques and strategies for clinicians, 2nd edition. Clifton Park: Thomson Delmar Learning.
  73. Stinchfield, S. M., & Young, E. H. (1938). Children with delayed or defective speech: Motor-kinesthetic factors in their training. Stanford: Stanford University Press.
  74. Travis, L. E. (1931) Speech pathology: A dynamic neurological treatment of normal speech and speech deviations. New York: Appleton-Century.
  75. Tuchmn, D. N., & Walter, R. S. (1994) Disorders of feeding and swallowing in infants and children. San Diego: Singular.
  76. Van Riper, C. (1954, 1947, 1939). Speech correction: Principles and methods. New York: Prentice-Hall.
  77. Van Hattum, R. J. (1980) Communication disorders: An introduction. New York: McMillan.
  78. Vaughn, G. R., & Clark, R. M. (1979). Speech facilitation: Extraoral and intraoral stimulation technique for improvement of articulation skills. Springfield: Charles C. Thomas.
  79. Weiss, C. E., & Lillywhite, H. S., & Gordon, M. E. (1980) Clinical management of articulation disorders. St. Louis: C. V. Mosby Co.
  80. West, R., & Kennedy, L., & Carr, A., & Backus, O. (1947). The rehabilitation of speech. New York: Harper & Brothers.
  81. Winitz, H. (1975) From syllable to conversation. Baltimore: University Park Press.
  82. Wilson, J. M. (Ed.) (1978) Oral-motor function and dysfunction in children. Conference proceedings, May 25-28, 1977. Chapel Hill: University of North Carolina.
  83. Yorkson, K. M., & Beukelman, D. R., & Strand, E. A., & Bell, K. R. (1999). Management of motor speech disorders in children and adults. Austin: Pro-Ed.
  84. Young, E. H., & Hawk, S. S. (1955) Motokinesthetic speech training. Stanford: Stanford University Press.

 

APPENDIX A

Publications reviewed for the study by treatment area.


ARTICULATION

  • Anderson, V. A. (1953) Improving the child's speech. New York: Oxford University Press.
  • Berry, M. F., & Eisenson, J. (1956) Speech disorders: Principles and practices of therapy. New York: Appleton-Century-Crofts.
  • Bleile, K . M. (2006) The late eight. San Diego: Plural.
  • Borden, R. C., & Busse, A. C. (1929). Speech Correction. New York: F. S. Crofts & Co.
  • Bosley, E. C. (1981) Techniques for articulatory disorders. Springfield: Charles C. Thomas.
  • Carrell, J. A. (1968) Disorders of articulation. Englewood Cliffs: Prentice-Hall.
  • Costello, J. M. (Ed.) (1984). Speech disorders in children: Recent advances. San Diego: College-Hill.
  • Czesak-Duffy, B. A. (1993). Triathlon Articulation Training. Kearney, NJ: Creative Communication Concepts.
  • Daniloff, R. G. (Ed.) (1984) Articulation assessment and treatment issues. San Diego: College Hill.
  • Diedrich, W. M., & Bangert, J. (1980) Articulation Learning. Houston: College-Hill.
  • Fletcher, S. G. (1992). Articulation: A physiological approach. San Diego: Singular.
  • Flowers, A. M. (2003). The big book of sounds, 5th edition. Austin: Pro-Ed.
  • Folk, M. J. (1992). Straight speech. Vero Beach, FL: Speech Bin.
  • Hanson, M. L. (1983) Articulation. Philadelphia: W. B. Saunders.
  • Hawk, S. S., and Young, E. H. (1955). Moto-kinesthetic speech training. Stanford: Stanford University Press.
  • Irwin, J. V. (1972) Disorders of articulation. Indianapolis: Bobbs-Merrill.
  • Kantner, C. E., & West, R. (1933) Phonetics: An introduction to the principles of phonetic science from the point of view of English speech. New York: Harper & Brothers.
  • Marshalla, P. J. (2007). Frontal lisp, lateral lisp: Articulation and oral-motor procedures for diagnosis and treatment. Mill Creek, WA: Marshalla Speech and Language.
  • Marshalla, P. J. (2004). Successful R therapy: Take your oral-motor and articulation therapy to new heights. Mill Creek, WA: Marshalla Speech and Language.
  • McDonald, E. T. (1964) Articulation Testing and treatment: A sensory-motor approach. Pittsburgh: Stanwix House.
  • Nemoy, E. M., & Davis, S. F. (1954, 1937). The correction of defective consonant sounds. Magnolia, MA: Expression.
  • Newman, P. W., & Creaghead, N. A., & Second, W. (1985) Assessment and remediation of articulatory and phonological disorders. Columbus: Charles E. Merrill.
  • Scripture, E. W. (1912). Stuttering and lisping. New York: MacMillan.
  • Secord, W. A., & Boyce, S. E., & Donohue, J. S., & Fox, R. A., & Shine, R. E. (2007). Eliciting sounds: Techniques and strategies for clinicians, 2nd edition. Clifton Park: Thomson Delmar Learning.
  • Sommers, R. K. (Ed.) (1983) Articulation disorders. Remediation of communicaion disorders series. Martin, F. N. (Series Editor). Englewood Cliffs: Prentice-Hall.
  • Stinchfield, S. M., & Young, E. H. (1938). Children with delayed or defective speech: Motor-kinesthetic factors in their training. Stanford: Stanford University Press.
  • Travis, L. E. (1931) Speech pathology: A dynamic neurological treatment of normal speech and speech deviations. New York: Appleton-Century.
  • Van Riper, C. (1954, 1947, 1939). Speech correction: Principles and methods. New York: Prentice-Hall.
  • Vaughn, G. R., & Clark, R. M. (1979). Speech facilitation: Extraoral and intraoral stimulation technique for improvement of articulation skills. Springfield: Charles C. Thomas.
  • Weiss, C. E., & Lillywhite, H. S., & Gordon, M. E. (1980) Clinical management of articulation disorders. St. Louis: C. V. Mosby Co.
  • West, R., & Kennedy, L., & Carr, A., & Backus, O. (1947). The rehabilitation of speech. New York: Harper & Brothers.
  • Weston, A. J., & Leonard, L. B. (1976) Articulation disorders: Methods of evaluation and treatment. Lincoln: Cliffs Notes.
  • Winitz, H. (Ed.) (1984) Treating articulation disorders: For clinicians by clinicians. Baltimore: University Park Press.
  • Winitz, H. (1975) From syllable to conversation. Baltimore: University Park Press.
  • Young, E. H., & Hawk, S. S. (1955) Motokinesthetic speech training. Stanford: Stanford University Press.


PHONOLOGY

  • Bernthal, J. E., & Bankson, N. W. (1994) Child phonology: Characteristics, assessment, and intervention with special populations. Current therapy of communication disorders series. Perkins, W. H. (Series Ed.) New York: Thieme.
  • Blodgett, E. G., & Miller, V. P. (1990) Easy does it for phonology: A complete program to remediate phonological disorders in young children. East Moline: LinguiSystems.
  • Crary, M. (1982) Phonological intervention: Concepts and procedures. San Diego: College-Hill.
  • Edwards, M. L., & Shriberg, L. D. (1983) Phonology: Applications in communicative disorders. San Diego: College-Hill.
  • Elbert, M., & Gierut, J. A. (1986) Handbook of clinical phonology: Approaches to assessment and treatment. San Diego: College-Hill.
  • Hodson, B. W., & Paden, E. P. (1983, 1991). Targeting intelligible speech: A phonological approach to remediation. San Diego: College Hill.
  • Ingram, D. (1976) Phonological disability in children. New York: Elsevier.
  • Lowe, R. J. (1994) Phonology: Assessment and intervention applications in speech pathology. Baltimore: Williams & Wilkins.


COMBINED ARTICULATION and PHONOLOGY

  • Bauman-Waengler, J. (2004, 2000). Articulatory and phonological impairments: A clinical focus. Boston: Pearson.
  • Bernthal, J. E. & Bankson, N. W. (2004, 1981). Articulation and phonological disorders. Boston: Pearson.
  • Creaghead, N. A., Newman, P. W., & Secord, W. A. (1989) Assessment and remediation of articultory and phonological disorders, 2nd edition. Columbus: Merrill.
  • Newman, P. W., & Creaghead, N. A., & Second, W. (1985) Assessment and remediation of articulatory and phonological disorders. Columbus: Charles E. Merrill.
  • Pena-Brooks, A., & Hedge, M. N. (2000) Assessment and treatment of articulation and phonological disorders in children. Austin: Pro-Ed.


MOTOR SPEECH (including cerebral palsy)

  • Brookshire, R. H. (1992). An introduction to neurogenic communication disorders, 4th edition. St. Louis: Mosby.
  • Crary, M. A. (1993). Developmental motor speech disorders. San Diego: Singular Publishing Group.
  • Darley, F. L., & Aronson, A. E., & Brown, J. R. (1975) Motor speech disorders. Philadelphia: W. B. Saunders.
  • Dworkin, J. P. (1991). Motor speech disorders: A treatment guide. St. Louis: Mosby.
  • Duffy, J. R. (1995) Motor speech disorders: Substrates, differential diagnosis, and management. St. Louis: Mosby.
  • Hardy, J. C. (1983) Cerebral palsy. Remediation of communication disorders series. Martin, F. N. (Ed.) Englewood Cliffs: Prentice-Hall.
  • Kaufman, N. (2006) The Kaufman speech praxis workout book: Treatment materials and a home program for childhood apraxia of speech. Gaylord, MI: Northern Rehabilitation Services.
  • Kelso, J. A. S., & Munhall, K. G. (Eds.) (1988). R. H. Stetson's Motor Phonetics: A retrospective edition. Boston: College-Hill.
  • Langley, M. B., & Lombardino, L. J. (Eds.) (1991) Neurodevelopmental strategies for managing communication disorders in children with severe motor dysfunction. Austin: Pro-Ed.
  • Love, R. J. (1992) Childhood motor speech disability. New York: Merrill.
  • McDonald, E. T., & Chance, B. (1964) Cerebral palsy. Englewood Cliffs: Prentice-Hall.
  • McNeil, M. R., & Rosenbeck, J. C., & Aronson, A. E. (Eds.) (1984) The dysarthrias: Physiology, acoustics, perception, management. San Diego: College-Hill.
  • Mysak, E. D. (1980). Neurospeech therapy for the cerebral palsied: A neuroevolutional approach, 3rd edition. New York: Teachers College Press.
  • Perkins, W. H. (Ed.) (1983) Dysarthria and apraxia. Current trends of communication disorders. New York: Thieme.
  • Rosenbek, J. C., & McNeil, M. R., & Aronson, A. E. (1984) Apraxia of speech: Physiology, Acoustics, Linguistics, Management. San Diego: College-Hill.
  • Vogel, D., & Cannito, M. P. (Eds.) (1991) Treating disordered speech motor control: For clinicians by clinicians. Austin: Pro-Ed.
  • Yorkson, K. M., & Beukelman, D. R., & Strand, E. A., & Bell, K. R. (1999). Management of motor speech disorders in children and adults. Austin: Pro-Ed.


FEEDING and DYSPHAGIA (adult and pediatric)

  • Arvedson, J. C., & Brodsky, L. (Eds.) (1993) Pediatric swallowing and feeding: Assessment and management. San Diego: Singular.
  • Groher, M. E. (1984) Dysphagia: Diagnosis and management. Boston: Butterworths.
  • Langley, J. (1988) Working with swallowing disorders. Bicester, Oxon: Winslow Press.
  • Logemann, J. A. (1983) Evaluation and treatment of swallowing disorders. San Diego: College-Hill.
  • Morris, S. E., & Klein, M. D. (2000, 1987). Pre-feeding skills: A comprehensive resource for mealtime development, 2nd addition. Austin: Pro-Ed.
  • Morris, S. E. (1982) The normal acquisition of oral feeding skills: Implications for assessment and treatment. Conference proceedings. Boston, MA June 20-23, 1981. Central Islip: Therapeutic Media.
  • Tuchmn, D. N., & Walter, R. S. (1994) Disorders of feeding and swallowing in infants and children. San Diego: Singular.


OROFACIAL MYOLOGY

  • Garliner, D. (1981) Myofunctional therapy. Coral Gables: Institute for Myofunctional Therapy.
  • Hanson, M. L., & Barrett, R. H. (1988) Fundamentals of orofacial myology. Springfield: Charles C. Thomas.


ORAL MOTOR

  • Bahr, D. C. (2001). Oral motor assessment and treatment: Ages and stages. Boston: Allyn and Bacon.
  • Gangale, D. C. (1993). The source for oral-facial exercises. East Moline, IL: LinguiSystems.
  • Marshalla, P. J. (1992). Oral motor techniques in articulation and phonological therapy. Seattle: Innovative Concepts.
  • Rosenfeld-Johnson, S. (2001) Oral-motor exercises for speech clarity. Tucson: Talk Tools.
  • Rosenfeld-Johnson, S. (2005) Assessment and treatment of the jaw. Tucson: Talk Tools.
  • Wilson, J. M. (Ed.) (1978) Oral-motor function and dysfunction in children. Conference proceedings, May 25-28, 1977. Chapel Hill: University of North Carolina.


INTRODUCTORY (OR BROAD-BASED) SPEECH-LANGUAGE

  • Hegde, M. N. (1998) Treatment procedures in communicative disorders. Austin: Pro-Ed.
  • Travis, L. E. (1971) (Ed.) Handbook of speech pathology and audiology. Englewood Cliffs: Prentice-Hall.
  • Van Hattum, R. J. (1980) Communication disorders: An introduction. New York: McMillan.


GUIDE BOOKS FOR PARENTS

  • Dougherty, D. P. (2005) Teach me how to say it right. Oakland: New Harbinger.

 

APPENDIX B

Authors from our study who served as president of the American Speech-Language-Hearing Association (Source: American Speech-Language-Hearing Association Action Center):

Authors and Term(s)

• Robert W. West 1925-28
• Lee E. Travis 1935-36
• Sara Stinchfield-Hawk 1939-40
• Jon Eisenson 1958
• Rolland J. Van Hattum 1977
• Jerilyn A. Logemann 1994, 2000
• John E. Bernthal 2001
• Nancy A. Creaghead 2002

Please cite this article as:

Marshalla, P. (2008). Oral Motor Treatment vs. Non-speech Oral Motor Exercises. Oral Motor Institute, 2(2). Available from www.oralmotorinstitute.org.

Permalink URL: www.oralmotorinstitute.org/mons/v2n2_marshalla.html

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