Oral Motor Institute
Volume 4, Monograph No. 1, 20 January 2012
THE ORAL MOTOR DEBATE - PART III
Keywords: oral motor treatment, nonspeech oral exercise, controversy, evidence-based practice
Part III of this article series explores the continued evolution of the "oral motor treatment" debate. It discusses speech-language pathology (SLP) research needs, evidence-based assessment and treatment development, and training ideas that may help resolve the nearly decade-long controversy.
Pertinent literature between 2008 and 2010 was reviewed on the topic. Three-hundred fifty-three speech-language pathologists (SLPs) from across the United States of America, including Puerto Rico, were surveyed regarding potential resolutions for the controversy.
Between 60 and 78 percent of surveyed SLPs indicated a desire for coordinated research (i.e., academics3 and clinicians working together) and training (i.e., coursework offered from undergraduate through continuing education) on the various aspects of oral sensory-motor assessment and treatment (e.g., feeding, motor speech, orofacial myology, etc.).
SLPs want the "oral motor treatment" controversy resolved. While the debate focused on a narrow4 aspect of SLP practice, it revealed research, assessment, treatment, and training ideas that apply across SLP practice areas. Application of these ideas could greatly benefit SLPs and SLP consumers.
Part III explores the continued evolution of the "oral motor treatment" controversy between 2008 and 2010. A review of relevant literature provides the background, and the following questions are considered:
- What continues to concern clinicians and academics regarding the "oral motor treatment" controversy?
- How can the evidence-base for, and required research on, oral sensory-motor assessment and treatment be attained?
- Is there a way to coordinate assessment, treatment, and training materials as well as undergraduate, graduate, and continuing education programs on this topic?
- How can academics and clinicians work together to accomplish all three aspects of evidence-based practice (EBP)?
Three-hundred fifty-three SLPs (speech-language pathologists) from across the United States of America (USA), including Puerto Rico, completed the "Survey for Future Research" (Appendix C; Bahr, 2008b). The survey had been initiated by the Oral Motor Institute (OMI)5 study group to explore resolutions for the "oral motor treatment" controversy. Demographics and specific administration procedures for this survey were reported in Part I (Bahr, 2011a). Some resolutions for the controversy were discussed in Part II (Bahr, 2011b). The discussion of "best current evidence," evidence-based systematic reviews (EBSRs), and opinion vs. research provides the background for the data and ideas presented in Part III.
Despite much recent discussion surrounding "best current evidence," the American Speech-Language-Hearing Association (ASHA) has not adopted a standard scale for rating "levels of evidence."6 However, ASHA's National Center for Evidence-Based Practice (N-CEP) has developed and implemented a 17-step EBSR process to help SLPs find the "best current evidence." In 2009, one EBSR was completed on the use of nonspeech oral exercises in speech treatment (the apparent topic of the "oral motor treatment" debate). By comparison, 14 theoretical opinion articles were published on the topic in 2008. While theoretical articles are informative, empirical research is needed to prove or disprove the effectiveness of clinical practices.
"Best Current Evidence" (One Aspect of Evidence-Based Practice)
Evidence-based practice (EBP) is important in the SLP field. ASHA's "Introduction to Evidence-Based Practice" (n.d.-b, p. 1) states, "the goal of EBP is the integration of: (a) clinical expertise, (b) best current evidence, and (c) client values to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve." ASHA's 2011 president Dr. Paul R. Rao (June 2011) said, "EBP is not about identifying the one best approach - it is about deciding which among the many acceptable options is likely to work best for a particular individual."
During the nearly decade-long "oral motor treatment" controversy, clinicians and academics appeared to assign differing levels of importance to the three aspects of EBP. Clinicians seemed most concerned about their "clinical expertise" being valued when serving "the interests, values, needs, and choices" of their clients and patients. Academics (speaking and writing about the controversy) appeared most concerned about the availability of the "best current evidence."
"Best current evidence" is usually discussed relative to a rating scale. However, no single scale for rating levels of evidence exists. In fact, Lohr reported that over 100 such scales were in existence in 2004. This has made it difficult for SLPs to effectively evaluate and discuss available empirical research and other forms of evidence.
Two examples of potential rating scales (for use by SLPs) were provided by Robey (ASHA Leader article, 2004) and ASHA (Technical Report, 2004). Robey (2004, p. 3) developed a chart entitled "Example Levels of Evidence" based on information from the Agency for Healthcare Research and Quality (2002 a & b). ASHA's Research and Scientific Affairs Committee (2004, p. 2) produced an example entitled "Levels of Evidence for Studies of Treatment Efficacy" based on information from the Scottish Intercollegiate Guideline Network (2002).
Empirical research is crucial for the generation of "best current evidence." The Publication Manual of the American Psychological Association (2010, p. 10) defines "empirical studies" as "reports of original research" that "test hypotheses by presenting novel analyses of data not considered addressed in previous reports." All of Robey's "Example Levels of Evidence" (2004) involved empirical research. However, ASHA's chart/example (2004) differed significantly from Robey's with regard to "Level 4/IV" evidence. Robey's "Level 4" suggested "observational studies without controls" (i.e., empirical research that tests a working hypothesis via observation). ASHA's "Level IV" suggested "expert committee report, consensus conference, [and] clinical experience of respected authorities." Table 1 compares ASHA's and Robey's charts/examples.
ASHA's suggestion for Level IV assigned value to clinical review and expertise. Yet, the title of ASHA's chart/example contained the term "studies" (implying empirical research). This discrepancy may have caused some confusion among SLPs, since many seem to equate the terms "evidence" and "studies" with empirical research alone. This did not appear to be ASHA's intent, judging by the contents of their chart/example.
Reportedly, ASHA has not adopted an official scale reflecting levels of evidence.7 Yet, Lass and Pannbacker (2008, p. 410) reported that the scale "adapted from the Scottish Intercollegiate Guideline Network (2002)" was "employed by ASHA." Apparent information conflicts such as these make it difficult for academics and clinicians to decide what constitutes evidence and what does not. An official scale, adopted by ASHA and named to reflect the content, would help resolve this problem.
|"Example Levels of Evidence" (Robey, 2004, p. 3)||"Levels of Evidence for Studies of Treatment Efficacy" Example (ASHA, 2004, p. 2)|
|1A: "Meta-analysis of multiple well-designed controlled studies"||Ia: "Well-designed meta-analysis of >1 randomized controlled trial"|
|1: "Well-designed randomized controlled trials"||Ib: "Well-designed randomized controlled study"|
|2: "Well-designed non-randomized controlled trial (quasi-experiments)"||IIa: "Well-designed controlled study without randomization"|
|IIb: "Well-designed quasi-experimental study"|
|3: "Observational studies with controls (retrospective studies, interrupted time-series studies, case-control studies, cohort studies with controls)"||III: "Well-designed nonexperimental studies, i.e., correlational and case studies"|
|4: "Observational studies without controls (cohort studies without controls and case series)"||IV: "Expert committee report, consensus conference, clinical experience of respected authorities"|
Evidence-Based Systematic Reviews (EBSRs)
In 2005, ASHA's N-CEP surveyed ASHA members via the "Knowledge-Attitudes-Practices Survey" to determine what SLPs needed to effectively progress toward EBP. The N-CEP found the following:
Survey respondents remarked that they had little or no time to search and analyze the peer-reviewed literature. Further, the majority of clinicians reported that the evidence for effective clinical practice was nonexistent, conflicting, or irrelevant and ultimately identified a number of clinical areas in need of further examination (Frymark, Schooling, Mullen, Wheeler-Hegland, Ashford, McCabe, Musson, & Hammond, 2009, p. 175).
EBSRs seemed to be one answer to these problems as they are compilations and discussions of best-available empirical evidence pertaining to clinical questions. They are meant to help practicing SLPs evaluate data in a streamlined fashion, so that the most effective methods may be chosen and incorporated into clinical practice. Justice and Fey (2004) recommended EBSRs of published research as a first step in helping SLPs find the "best current evidence."
EBSRs are qualitatively different from typical reviews of the literature found in most journal articles. They are a 17-step process (Mullen, 2006) involving the "critical appraisal of study quality," "identification of study by phase/stage of clinical research," and "synthesis of the body of evidence by quality and stage of research" (Frymark, et al., 2009, p. 177). However, the "level of evidence" under which EBSRs fall (See Table 1) is a question for ASHA's N-CEP.
In 2009 and 2010, ASHA's N-CEP completed seven EBSRs on nonspeech and behavioral/nonfeeding/nonswallowing oral sensory-motor treatments. With so much discussion surrounding the topic of oral exercise, these EBSRs (summarized in Appendix A) seemed to be a logical "starting point" for ASHA's N-CEP. However, six of these EBSRs addressed feeding and swallowing, while only one addressed the use of nonspeech oral exercise in speech treatment (the apparent topic of the "oral motor treatment" controversy). The single EBSR on nonspeech oral exercise revealed "insufficient evidence to support or refute the use of OMEs [oral motor exercises] to produce effects on speech...in the research literature" (McCauley, Strand, Lof, Schooling, & Frymark; November 2009, p. 343), confirming SLPs' observations that empirical research frequently identified areas for further study rather than "evidence for effective clinical practice" (Frymark, et al., 2009, p. 175).
While the EBSRs on oral sensory-motor treatment were a good "starting point" for ASHA's N-CEP, EBSRs, meta-analyses, and empirical studies of the many forms of pediatric speech treatment are greatly needed. According to the United States Department of Labor, approximately 48 percent of SLPs worked in educational settings in 2010. ASHA's 2010 Schools Survey - SLP Caseload Characteristics Report revealed that 91.6 percent of school-based SLPs treated articulation/phonological disorders and 58.8 percent addressed childhood apraxia of speech (CAS), while only 9.4 percent treated feeding and swallowing disorders. ASHA's 2009 "Health Care Survey" revealed that SLPs in healthcare spent a greater portion of their time (i.e., 24 percent) treating articulation and phonological disorders than pediatric feeding and swallowing (i.e., 16 percent). In light of the large percentages of SLPs treating pediatric speech disorders, it is essential the empirical research be conducted on specific speech treatments (e.g., "bottom-up," "hierarchical," "auditory-visual," "tactile-proprioceptive," etc.) and populations (e.g., CAS, childhood dysarthria, articulation disorders, phonological disorders, etc.).
Opinion vs. Empirical Research
In contrast to the single EBSR on the use of oral exercise in speech treatment (McCauley, et al., 2009), most other recent articles on this topic have been theoretical in nature (expressing the ideas and opinions of the authors). These articles stressed the importance of empirical research, yet many of the authors had not done empirical studies on the topic. Therefore, no new empirical data was provided for SLPs' clinical decision-making.
In 2008, a total of 14 theoretical articles were published on the topic of nonspeech oral sensory-motor treatment. The five-article "Clinical Forum" series (found in LSHSS)9 was discussed in Part II (Bahr, 2011b). Another nine theoretical articles appeared in Seminars in Speech and Language (Volume 29, Number 4). A tenth article in this series was a research article (Forrest & Iuzzini, 2008). The nine theoretical articles in Seminars in Speech and Language (Volume 29, Number 4) added to the SLP knowledge base because authors from different areas of the field discussed a variety of treatment populations relative to the topic (summarized in Appendix B). Despite the usefulness of theoretical journal articles, empirical research is greatly needed.
Most of the theoretical articles on the topic of nonspeech oral sensory-motor treatment were informational. However, three authors (Lass & Pannbacker, 2008; Kamhi, 2008) expressed strong opinions regarding nonspeech oral sensory-motor treatments and the SLPs perceived as promoting them. For example, Kamhi (2008, p. 337) stated:
As I found more and more reasons to explain the use of NSOMEs [nonspeech oral motor exercises], I began to think that the more interesting question was to determine why a clinician is not using NSOMEs. The small percentage of clinicians (< 15%) who do not use NSOMEs  must strongly believe that these activities have absolutely no value for speech sound production. Someone needs to sample these clinicians to find out how they have been able to resist the allure of NSOMEs. The next step would be to recruit these "NSOME-resisters" to spearhead a practitioner-directed attack against the use of NSOMEs to treat children with speech sound disorders. I hope that the guest editor of this issue [Gregory L. Lof, PhD] will continue to lead us in the ongoing battle to reduce the widespread and indiscriminate use of NSOMEs.
According to Kamhi (2008), G. Lof appeared to be waging a war. Similar yearly ASHA convention presentations and handouts by Lof and others (e.g., Lof & Watson, 2005; Lof, 2006, 2007, 2008a, & 2009) may have perpetuated this idea. Pannbacker and Lass (who were also openly opposed to the use of nonspeech activities and exercises) presented frequently at ASHA conventions (Pannbacker & Lass, 2002, 2003, & 2004; Lass, Pannbacker, Carroll, & Fox, 2006). Rather than a debate (where both sides were equally represented), there seemed to be a campaign against those who used the term "oral motor treatment" to describe their work.
As examples, Lass and Pannbacker (2008, p. 415) and Kamhi (2008, p. 336) expressed a number of written claims, concerns, and opinions regarding SLPs they appeared to perceive as promoting the indiscriminate use of nonspeech oral sensory-motor treatment. They included the Oral Motor Institute (OMI) study group in their claims. Table 2 compares some of these claims, concerns, and opinions relative to information found contrary to them.
|CONCERNS/CLAIMS/OPINIONS EXPRESSED||INFORMATION CONTRARY TO CONCERNS/CLAIMS/OPINIONS|
|Kamhi (2008, p. 336) said, "Publishing companies and individuals (e.g., Pam Marshalla and colleagues' Oral Motor Institute) that promote and market oral sensory and motor treatments also contribute to the widespread use of NSOMEs."|
|Kamhi (2008, p. 336) named one set of treatment materials (i.e., "the 'Can Do' oral motor games published by Super Duper Publications") as an example of the 869,000 hits found in his Google search for oral motor activities. Kamhi implied that the large number of hits on Google indicated the widespread use of nonspeech oral exercises.|
|Lass and Pannbacker (2008, p. 415) said, "Much of the evidence about NSOMTs [nonspeech oral motor treatments] has been generated by its developers. Thus, reports may be generated to promote products (i.e., materials, workshops, etc.). Furthermore, some developers have made misleading and/or unsubstantiated statements about NSOMTs."|
|Lass and Pannbacker (2008, p. 415) said, "Related to this discussion is the recently established Oral Motor Institute (OMI). The purpose of the OMI is to publish monographs about oral motor treatments for feeding and articulation.... The monographs were peer reviewed; however, the reviewers were developers of oral motor materials and providers of oral motor workshops." Lass and Pannbacker seemed to be referring to the 17 OMI board members with this comment.|
|Lass and Pannbacker (2008, p. 418) said, "There is a proliferation of NSOMT workshops that provide CEUs.... Recently, Lof (2006) said that 'the goal of speech therapy is NOT to produce a tongue wag, to have strong articulations, to puff out the cheeks, etc.' (p. 7). Rather, the goal is to improve speech."|
Kamhi (2008) and Lass and Pannbacker (2008) made strong statements and claims regarding the OMI study group, continuing education, and SLPs they perceived as supporting nonspeech oral sensory-motor treatment. However, independent study groups like the OMI are usually considered an asset in a field of study. They tend to bring fresh perspectives and "clinical expertise" (an aspect of EBP) to the topics under discussion. It would be difficult to find a study group, a professional journal group, or an organization (e.g., ASHA) in which the members do not have some vested interest. Such interests are disclosed as part of advertising and publication.
Two statements from ASHA's Code of Ethics (2010) have been points of interest throughout the three-part "Oral Motor Debate" series. The claims, concerns, and opinions listed in Table 2 (Kamhi, 2008; Lass & Pannbacker, 2008) should be considered in light of these statements.
ASHA's Code of Ethics (2010, p. 4) states, "Individuals' statements to colleagues about professional services, research results, and products shall adhere to prevailing professional standards and shall contain no misrepresentations." The concerns expressed by Kamhi (2008) and Lass and Pannbacker (2008) regarding continuing education and the OMI seemed mostly unfounded and inaccurate (See Table 2). However, they may help explain some of the concerns expressed by SLPs in Part I of this article series (Bahr, 2011a) and the perception that academics and clinicians were on opposite sides of the controversy (discussed in Part II; Bahr, 2011b).
Additionally, ASHA's Code of Ethics (2010b, p. 4) states, "Individuals shall uphold the dignity and autonomy of the professions, maintain harmonious interprofessional and intraprofessional relationships, and accept the professions' self-imposed standards." The use of words such as "attack" and "battle" in professional journal literature (Kamhi, 2008, p. 337) does not promote this goal. The SLP profession would be better served by cooperative and collaborative professional efforts that focus on improving SLP research, training, assessment, and treatment.
In a 2008(b) ASHA convention poster session, Bahr asked some questions in response to the concerns and claims expressed by Kamhi, Lass, Pannbacker, and others:
- "Are continuing education courses really promoting nonspeech treatments in place of speech treatment ...?"
- "Do SLPs trained, certified, and licensed according to ASHA standards really provide therapy consisting largely or exclusively of nonspeech or nonfeeding work with the expectation of improvement in speech or feeding?"
- "Would a properly trained SLP [speech-language pathologist] do oral awareness/discrimination and oral activities/exercises with children who do not need them ...? If so, are these therapists properly trained?"
Three questions were then queried in the simple one-page "Survey for Future Research" (Appendix C) developed by Bahr (2008b):
- "What is being taught at the undergraduate and graduate levels on feeding, motor speech, and mouth function? Are students still being taught how to adequately conduct, interpret, and use the results of an oral examination?"
- "How can continuing education better meet the needs of working therapists? Is there a way to better coordinate undergraduate, graduate, and continuing education on the topic of oral motor assessment and treatment as well as other topics?"
- "Is there a professional interest in an updated text on oral motor assessment and treatment? Should researchers and practicing clinicians collaborate on this?"
These and other questions from "Survey for Future Research" (Appendix C; Bahr 2008b) targeted ideas for the resolution of the "oral motor treatment" debate. The results and discussion of this survey follow.
RESULTS AND DISCUSSION
"Survey for Future Research" Summary of Results
Three-hundred fifty-three SLPs from across the USA, including Puerto Rico, completed the "Survey for Future Research" (Appendix C; Bahr 2008b). This survey explored resolutions for the "oral motor treatment" controversy by asking respondents to identify questions they would like addressed on the topic. The questions seemed pertinent to the surveyed SLPs, as 60 percent or more responded to each question. Those completing the survey appeared to have an interest in the topic, as they either attended an ASHA convention presentation or participated in a website on the topic. Refer to Part I (Bahr, 2011a) for demographics and specific administration procedures for this survey. Table 3 summarizes the results of the "Survey for Future Research."
Questions 1 and 6 from the "Survey for Future Research" were discussed in Part II (Bahr, 2011b). Regarding "Question 1," 92 percent of the respondents were interested in a "clear definition of oral motor function and the many aspects of oral motor treatment (i.e., feeding/oral phase swallowing, motor speech, orofacial myology, oral awareness/discrimination, and oral activities/exercises)" to "help researchers and clinicians use this terminology more accurately." Regarding "Question 6," 79 percent of the surveyed SLPs were concerned about the appropriate place for and "use of nonspeech and/or nonfeeding oral sensory-motor treatments with appropriate populations."
"Question 7" yielded 173 written comments and questions covered in the next section. Questions 2 through 5 queried oral sensory-motor research and training needs/ideas discussed in subsequent sections of this article.
|QUESTION||PERCENTAGE OF SLPS CONSIDERING THIS QUESTION IMPORTANT|
|1. Would a clear definition of oral motor function and the many aspects of oral motor treatment (i.e., feeding/oral phase swallowing, motor speech, orofacial myofunctional treatment, oral awareness/discrimination, and oral activities/exercises) help researchers and clinicians use the terminology more accurately?||92%|
|2. How can SLPs become more cohesive as a profession? Could group-design research projects combining the efforts of researchers (often doctoral level SLPs) with SLPs who carry active caseloads (often master's level SLPs) be developed?||60%|
|3. What is being taught at the undergraduate and graduate levels on feeding, motor speech, and mouth function? Are students still being taught how to adequately conduct, interpret, and use the results of an oral examination?||78%|
|4. How can continuing education better meet the needs of working therapists? Is there a way to better coordinate undergraduate, graduate, and continuing education on the topic of oral motor assessment and treatment as well as other topics?||75%|
|5. Is there a professional interest in an updated text on oral motor assessment and treatment? Should researchers and practicing clinicians collaborate on this?||77%|
|6. Is there an appropriate place and use of nonspeech and/or nonfeeding oral treatments with appropriate populations? What is this place and use?||79%|
|7. What other related questions do you have?||173 Written Questions and Comments Submitted|
Question 7: Written Comments and Questions
One-hundred seventy-three additional written comments or questions were submitted in response to "Question 7" of the "Survey for Future Research" (found in Appendix C). It asked, "What other related questions do you have?" SLPs seemed to have much to ask or say on the subject of oral sensory-motor treatment.
The largest percentage of questions and comments (i.e., 23 percent) involved evidence and research. Respondents were clear in their desire for more quality research to obtain definitive answers. More than one respondent pointed out the need for researchers and academics to work with clinicians to find answers. Respondents also wanted SLPs with clinical experience to work with researchers on developing evidence-based assessments to determine treatment effectiveness. Some SLPs expressed concerns regarding the current state of SLP research. They suggested that:
- researchers and academics were too far-removed from the types of problems clinicians face,
- academics and researchers were not researching clinically necessary and appropriate topics and populations, and
- treatments and techniques (with "larger" evidence bases) may reflect past or present topics of interest within the academic community instead of current consumer needs.
Education and training questions/comments comprised the next largest area of concern (i.e., 14 percent). Surveyed SLPs expressed that graduate school should adequately prepare students for the types of clients and patients they will treat once they are working. A number of respondents seemed concerned that they did not receive training on specific oral sensory-motor topics such as swallowing and feeding in their university programs; yet, ASHA and employers expected them to perform these types of treatment. Several respondents questioned the wisdom of expecting SLPs to address such critical needs as swallowing without specialty certification. Many surveyed SLPs expressed the desire for a variety of good-quality workshops to address oral sensory-motor function, feeding, and swallowing assessment/treatment, since they had not learned about these areas at their universities.
Thirteen percent of respondent comments and questions involved the impact of oral sensory-motor issues on speech and communication. Surveyed SLPs had many questions about treating clients and patients who exhibited significant speech concerns such as childhood apraxia of speech (CAS), childhood dysarthria, and other speech disorders beyond articulation and phonological concerns. Treatment for CAS appeared to be a particular area of concern for many clinicians. The PROMPT17 method (one reported treatment for CAS) generated a lot of confusion. Respondents wondered whether to consider PROMPT an oral sensory-motor treatment or not. They also wondered whether PROMPT was supported by empirical research.
Respondents commented on earlier developing skills that preceded speech development, including feeding and non-speech activities such as mouthing objects and other forms of mouth play. In light of the many developmental approaches to therapy, surveyed SLPs wondered why opponents of oral sensory-motor treatment did not value working on such earlier-developing skills. Some respondents expressed concerns that researchers and academics might be "missing the mark" by not addressing the underpinnings of speech problems.
Twelve percent of respondents' questions and concerns revolved around the oral sensory-motor treatment controversy and disagreement itself. Although one respondent questioned the need for agreement on the topic, the majority expressed discomfort regarding the conflict among members in the field. Some respondents expressed distress over the perception that others, within the field, seemed to be dictating therapy practices by asking SLPs to stop using techniques they found clinically successful. Most respondents expressed a desire for consensus that clinicians could use any method that they find works, without fear of censure by peers. While a couple of respondents indicated their disapproval of oral motor practitioners, more of the surveyed SLPs seemed annoyed with what they described as arrogance and a lack of open-mindedness in their peers. A number of comments indicated that SLPs would like ASHA to thoroughly research the topic and issue an official stand.
Eight percent of respondents had other treatment questions/comments, and another eight percent were concerned about the involvement of other disciplines. There were a number of questions aimed at the meaning of the term "evidence-based." Some respondents interpreted it to mean solely founded in statistical evidence, while others found importance in anecdotal evidence. One respondent asked if anecdotal evidence in the "real world ever trumps the results of studies contrived in the laboratory."
Misunderstanding appeared to abound within the questions and comments gathered from SLPs. Case in point, one participant said that she thought universities did not teach students to conduct, interpret, and use the results of an oral mechanism examination [a long-accepted and basic aspect of speech and swallowing assessment] because "it is not evidence-based."
Survey respondents also expressed interest in evidence and research by adjunct disciplines such as occupational therapy, physical therapy, orofacial myology, neurology, sports medicine, etc. A few respondents seemed concerned that other disciplines were "taking on" traditional SLP treatment roles while SLPs were arguing over "oral motor treatment."
Six percent of respondents' comments and questions involved definition and terminology. Surveyed SLPs requested a variety of information. Some asked for precise definitions18 of treatments to dispel confusion over therapy practices. A number indicated the importance of clarifying the types of oral sensory-motor treatment appropriate for particular populations and problems. Respondents seemed concerned that misunderstandings within the field may be the result of researchers, academics, and clinicians who are not discussing like practices nor precisely specifying the populations under discussion. Some respondents indicated a desire for more information on the definition and etiology of motor disturbances, while one respondent expressed a concern about how to measure successful oral sensory-motor treatment outcomes.
Another area of concern for respondents was the potential for "vested interest" in those SLPs who promote forms of oral sensory-motor treatment and sell products or services related to their practices. Survey takers expressed a desire for evidence from those without anything monetary to gain. This could be accomplished if researchers and the developers of products and services worked together.
The number of written questions and comments in response to the "Survey for Future Research" (Appendix C) indicated that the topic of oral sensory-motor assessment and treatment is important to clinicians. SLPs are still looking for answers, despite hearing generalities that "oral motor treatment" does not work. This fact, in itself, highlights the importance of the subject and the need for more than basic speech therapy techniques to address the complex cases SLPs treat in schools, hospitals, and clinics. Clearly, there is also a need for objective data to support or refute specific oral sensory-motor practices used in speech and feeding treatment. The data from "Question 7" can be found in Table 4.
|SLPS' QUESTION/COMMENT TOPICS REGARDING THE "ORAL MOTOR TREATMENT" CONTROVERSY||NUMBER OF QUESTIONS & COMMENTS||PERCENTAGE OF TOTAL|
|Impact of Oral Sensory Issues on Speech/Communication Treatment||23||13%|
|OT/PT/Other Discipline Involvement||13||8%|
|Other Treatment Questions/Comments||13||8%|
|Appreciation for Feedback Opportunity||11||6%|
|Whole-Child Treatment Approaches||4||2%|
Question 2: Attaining the Empirical Evidence-Base
"Question 2" from the "Survey for Future Research" (Appendix C) asked SLPs about the importance of clinicians and researchers working together on research projects. It read, "How can SLPs become more cohesive as a profession? Could group-design research projects combining the efforts of researchers (often doctoral level SLPs) with SLPs who carry active caseloads (often master's level SLPs) be developed?"
Sixty percent of surveyed SLPs circled "Question 2" as important, and an additional 40 written questions and comments were submitted on the topic (See Tables 3 and 4). The lower response percentage for this question compared to other survey questions may reflect SLPs' lack of confidence in clinicians and academics working together to resolve the problem (the essence of "Question 2"). However, the large number of questions and comments (almost double compared to other areas) revealed the importance of solving it.
The topics of empirical research and peer-reviewed journal literature were frequently discussed throughout the "oral motor treatment" controversy. Paucity of empirical research is not specific to oral sensory-motor treatment, despite the number of theoretical articles calling for research on the topic (See previous section "Opinion vs. Empirical Research"). Justice, Nye, Schwarz, McGinty, and Rivera (2008) reported limited group-design treatment research across SLP treatment areas when they reviewed the three major ASHA journals (i.e., AJSLP19, LSHSS, and JSLHR20) between 1997 and 2006. Paucity of peer-reviewed journal literature is also not specific to oral sensory-motor treatment. In a survey of 117 AJSLP articles between 2004 and 2007, Bahr (2008a) found limited peer-reviewed journal literature on most speech-related topics (i.e., motor speech, phonology, fluency, and voice). At the time, the majority of AJSLP articles focused on language and communication. The SLP field is in great need of treatment-oriented, empirical evidence and peer-reviewed journal literature across treatment areas.
In response to concerns within the SLP community regarding the generation of empirical research, Scaler Scott, Bahr, and Reardon-Reeves presented a collaborative research model at the 2009 ASHA Convention. The model supported ASHA's "Strategic Pathway to Excellence" (ASHA, n.d.-a) by suggesting the active participation of ASHA members (clinicians and researchers) in the generation of empirical research and the use of this evidence in clinical decision-making. Scaler Scott, Bahr, and Reardon-Reeves outlined a systematic plan to unite researchers (who comprise approximately 1 percent of ASHA's membership) and clinicians (who comprise approximately 81 percent of ASHA's membership) on crucial research projects (statistics from ASHA, Year-End 2006). Roadblocks that could preclude the success of this plan were also evaluated and discussed.
Figure 1 summarizes the research model suggested by Scaler Scott, Bahr, and Reardon-Reeves (2009). The first step in this model is to systematically match strengths, background, training, interests, and goals of academics and clinicians to create a research dyad. The clinician researcher provides the clinical caseload, teaches the academic researcher about the techniques/clinical procedures being studied, assesses and treats clients/patients, and takes data. The academic researcher mentors the clinician researcher as they set up the project, analyze the data, and write the resulting paper together.21 The academic researcher trains the clinician researcher to follow research protocol and assist with reliability checks. Proactive partnership, training, and coordination assist the dyad in working though individual and institutional roadblocks (e.g., knowledge gap, project time, funding, etc.). With a plan in place, crucial assessment/treatment research and improved relationships between academics and clinicians could result. Since clinicians tend to treat caseloads of individuals with similar problems, group-design research would be more likely to occur with this model, resolving the paucity of group-design research discussed by Justice, et al. (2008). Such research would provide empirical evidence for SLP clinical decision-making while meeting the needs of current clinical populations.
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Justice and Fey discussed the progression from empirical research to clinical practice (2004, pp. 7-8):
First comes the scaling up of research, or endorsing researchers' conduct and publication of research that targets real clinical problems and, ultimately, is implemented in non-laboratory, clinical settings. Second comes the scaling up of practices, or removing barriers that affect the translation of research findings to clinical practices.... EBP requires a synergy between the research community, which is charged with accumulating evidence, and the clinical community, which is charged with examining the preponderance of evidence, to make decisions about the best ways to evaluate and treat children.... Systemic changes are needed first at the organizational level, encompassing the discipline and its professional associations, and secondly, at the individual level."
Empirical research in the SLP field is usually based on clinical problems. Such research has the potential to validate or invalidate clinical procedures which ultimately impact client and patient outcomes/welfare. EBSRs (such as those summarized in Appendix A) may be a "first step" in resolving the apparent "disconnect" between empirical research and practice. A collaborative research model may be the next step, and a revised training model may help SLPs put empirical research into practice.
Questions 3, 4, and 5: Training Needs/Ideas
Three questions from the "Survey for Future Research" targeted SLP training needs/ideas relative the resolution of the "oral motor treatment" controversy (Bahr, 2008b; Appendix C). The response percentages were similar for all three questions. In response to "Question 3," 78 percent of surveyed SLPs said they were interested in knowing what was "being taught at the undergraduate and graduate levels on feeding, motor speech, and mouth function" and whether students were being taught to "conduct, interpret, and use" results from oral mechanism exams. In response to "Question 4," 75 percent of surveyed SLPs seemed concerned about ways continuing education could "better meet the needs" of working SLPs and whether there was a way to "coordinate undergraduate, graduate, and continuing education training." In response to "Question 5," 77 percent of surveyed SLPs indicated an interest in an updated textbook22 on oral sensory-motor assessment and treatment using a researcher-clinician collaborative model.
The survey results revealed that SLPs were concerned about SLP training in the areas of feeding, motor speech, and mouth function. Additional written questions and comments (See previous "Question 7" summary) indicated that SLPs were concerned about their ability to meet current consumer23 needs with their present training. Therefore, a different training model may better meet the needs of SLPs and SLP consumers as well as the standards of EBP. Two questions would be important for this process:
- What model could accomplish the coordination of training levels and programs from undergraduate through continuing education?
- What curriculum content flow could adequately train SLPs in the various aspects of oral sensory-motor treatment (e.g., feeding, swallowing, motor speech, and orofacial myology)?
Figure 2 is a conceptual model for evidence-based training that could be applied across the SLP field. In this model, "clinical expertise, best current evidence, and patient/client values" are inherent in all training levels (undergraduate training through continuing education). Textbooks, tutorials, assessment materials, and treatment materials (used as part of the training process) also reflect these three aspects of EBP. The arrows pointing from the tutorials, textbooks, and materials toward the various levels of SLP instruction demonstrate this concept. A training model, such as this, could help resolve many of the problems encountered in the "oral motor treatment" controversy (e.g., development of evidence-based assessment and treatment materials, updated SLP training on current treatments and populations, etc.).
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Currently, the SLP field seems to be at least partially meeting the requirements of this evidence-based training model. Textbooks and tutorials are developed from relevant literature review and the clinical expertise of the author(s).24 Assessment materials are based on developmental and other norms, as well as client/patient behavioral observations. Treatment materials usually contain suggested activities that SLPs have found successful and motivational in treatment. They are not prescriptive in nature, and clinicians use their expertise to choose appropriate treatment materials for clients and patients based on assessment results. Yet, the paucity of empirical research has significantly limited the availability of "best current evidence" for these processes. In fact, few recent assessment and treatment materials seem to reflect all three aspects of EBP including the supportive empirical research.25
With regard to SLP training, undergraduate and graduate programs adhere to ASHA's standards and requirements. ASHA provides limited curriculum guidelines26 and significant academic freedom. University training programs often vary relative to available faculty. The clinical or research interests and expertise of faculty may determine specific courses taught, how they are taught, and some clinical aspects of training programs (e.g., types of clients drawn to graduate clinics or placements for student clinicians). Therefore, students may not receive instruction or "hands-on" experience with the variety of clients/patients/consumers treated in clinics, schools, and hospital settings. This may ultimately limit their ability to make appropriate clinical decisions in the work environment.
Currently, continuing education (CE) is mostly consumer-driven. It is based on SLPs', clients', and patients' needs and usually focuses on clinical decision-making. SLPs frequently take courses that apply to their current clients/patients and available jobs within the field. CE courses often attempt to provide training that SLPs did not receive at the university level. ASHA and its Special Interest Groups (SIGs) provide CE opportunities. ASHA also has many affiliated CE Providers who agree to detailed standards for course development and administration. Both academics and experienced master clinicians teach CE courses.
The coordination of university training programs and CE could systematize SLP training. Such coordination would require that instructors have at least 5 to 10 years of clinical experience in the subjects they teach and an understanding of current empirical research. Students would then learn from experienced clinicians who could guide them to the "best current evidence" and teach them about the assessment and treatment of current clinical populations (e.g., children with autism, Down syndrome, CAS, dysarthria, orofacial myofunctional disorders, etc.).
Standardization of core curriculum at the graduate and undergraduate levels would allow CE to focus on advanced level, specialized training. A survey of what is currently taught in undergraduate, graduate, and continuing education programs would likely be the first step in studying the overall training process. A network of academics and clinicians who teach on similar topics could then be established, and "collective knowledge" could be used "to advance the goals" of the field (Rao, March 2011, p. 23).27 Team teaching (i.e., academics and master clinicians teaching together) could be effective at all training levels.
SLPs want and need specific and appropriate training to assess and treat clients with oral sensory-motor disorders that impact the functional processes of eating, drinking, and speaking. The idea of incorporating oral-sensory motor training into university programs is not new. Pierce and Taylor (2001) surveyed 128 SLPs, and 97 percent of their respondents "believed that more coursework on oral myofunctional disorders [was] needed in [university] training programs" (p. 27). They suggested that "speech pathologists, orofacial myologists, ASHA, IAOM [International Association of Orofacial Myology], colleges, and universities work together to improve undergraduate and graduate training programs so that practicing clinicians are adequately trained to provide assessment and treatment of orofacial myofunctional disorders" (p. 30).
In some South American countries, dentists and SLPs train together in university courses.28 SLPs, dentists, orthodontists, and others also train together in continuing education programs offered by the IAOM throughout the world. Interdisciplinary training with dentists and orthodontists likely provides SLPs with a better understanding of orofacial development, overall oral sensory-motor function, and the ways orofacial myofunctional phenomena can affect speech development and production. ASHA also has three SIGs that address the various aspects of oral sensory-motor function (i.e., SIG 2: Neurophysiology and Neurogenic Speech and Language Disorders; SIG 5: Speech Science and Orofacial Disorders; and SIG 13: Swallowing and Swallowing Disorders).
Table 5 represents one potential curriculum content flow from undergraduate training through CE for the topic of oral sensory-motor assessment and treatment. In this model, functional anatomy and physiology courses, taught at the undergraduate level, would be directly applicable to assessment and treatment. A course on typical sensory-motor development would provide information on detailed whole-body movement development (beginning at birth) that leads to task-specific processes (e.g., speech acquisition). A survey course on feeding, swallowing, orofacial myofunctional, and motor speech assessment/treatment in pediatric/adult populations would familiarize students with these areas prior to, or in conjunction with, observations of these techniques (in schools, clinics, and hospitals). Another survey course on research and scientific thinking would help students develop the habit of accessing and evaluating professional literature to assist in clinical problem solving. SLPAs (speech-language pathology assistants), who are usually trained at an undergraduate (associate or bachelor) level and work under the guidance of certified SLPs, would benefit from a similar foundation.29
In the "Table 5" model, two courses would be offered on oral sensory-motor assessment and treatment at the graduate level.30 There could be separate pediatric and adult courses on feeding, swallowing, orofacial myofunctional, and motor speech assessment and treatment. As another option, one course could be offered on the assessment and treatment of pediatric and adult feeding, swallowing, and orofacial myofunctional disorders, while a second course was offered on the assessment and treatment of pediatric and adult motor speech disorders.
With a relatively standard curriculum in place at the undergraduate and graduate levels of SLP training, CE courses could provide specialized and updated training in the areas of feeding, swallowing, motor speech, and orofacial myology. Such courses could provide a forum for SLPs to share their expertise, collate their knowledge, establish mentoring networks, and team with members of other disciplines, as appropriate.
|LEVEL OF STUDY||CONTENT|
|Undergraduate and SLPA (Speech-Language Pathology Assistant)|
|Continuing Education||Courses offering specialty foci in feeding, swallowing, orofacial myology, and motor speech. Other disciplines (e.g., occupational therapy and physical therapy) to participate in courses as appropriate for teaming and division of assessment/treatment responsibilities.|
Speech is a complex sensory-motor act. Yet, throughout the controversy, there was limited discussion of the sensory-motor processes and physical support systems involved in speech production. This was likely related to the fact that the debate initially focused on children with articulation and phonological disorders (who reportedly did not have oral sensory-motor problems). Children with motor speech disorders have now been added to the discussion. Specific information on muscle function, motor programming, and the systems supporting oral function is needed for sound clinical decision-making in the assessment and treatment of these pediatric populations (i.e., children with dysarthria and/or CAS).
Muscle Function, Motor Programming, and Systems that Support Oral Function
Two "building blocks" of movement (i.e., muscle tone and strength) were discussed by those expressing concerns about the use of NSOMTs and NSOMEs in speech treatment. Children with dysarthria have problems with strength and muscle tone; however, they were not the target population in the controversy. Strength is directly related to muscle tone. Weakness can result if muscle tone is too high or too low (Hillis & Bahr, 2001; Duffy, 1995). While muscle tone and strength are two crucial aspects of muscle function, movement is an extremely complex process based on equally complex sensory processing.
Figure 3 is a very simplified, conceptual model of the complex interrelatedness among the many sensory-motor components impacting the treatment of oral movement disorders. Three types of oral sensory-motor treatment (i.e., feeding/oral phase swallowing, orofacial myofunctional,32 and motor speech treatment) are listed toward the left side of Figure 3. Bidirectional arrows indicate a relationship among these treatment areas, as orofacial myofunctional treatment may involve oral phase swallowing and/or motor speech treatment.
Moving toward the right side of Figure 3, ideas are found regarding the potential relationships between muscle tone/function and motor plans/gestures.33 Adequate muscle tone (and the resulting muscle function) along with task-specific motor plans/gestures support the grading, dissociation, and direction of movement used in the task-specific processes of eating, drinking, and speaking. If muscle tone is too high or too low, the body is not ready for precise, differentiated movement. The development of unique and precise motor plans/gestures is based upon this "preparedness for movement."34 The apparent relationship between muscle function and motor programming may help explain why children with muscle function problems also tend to have motor programming problems (e.g., children with Down syndrome, children with cerebral palsy, etc.).
Listed on the right side of Figure 3 are some of the components thought to be directly related to muscle tone/function and motor programming. Proprioception (defined as "the inner awareness in the muscles and the joints") is a likely component of both processes. Eating, drinking, and speaking involve significant tactile-proprioceptive sensory processing (in addition to other sensory processing) and task-specific timing and coordination.
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An understanding of the systems in the body that support oral sensory-motor function is also needed to effectively assess and treat children with oral movement disorders. Eating, drinking, and speaking involve several systems. Figure 4 is another very simplified, conceptual model of these systems. Intelligible speech requires adequate respiratory and vocal support in addition to control over the oral and nasal areas. Effective eating and drinking require oral, nasal, and respiratory control as well as adequate pharygeal and esophageal function. The arrows in Figure 4 indicate the general direction of movement through the various systems that support eating, drinking, and speaking.
Figures 3 and 4 provide the background for subsequent discussions on phonological and articulation disorders vs. motor speech disorders. These figures serve as a simple reference and reminder of the complex sensory-motor bases for the functional processes of eating, drinking, and speaking.
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Phonological and Articulation Disorders vs. Childhood Apraxia of Speech (CAS) and Dysarthria
The "oral motor treatment" debate began with the discussion of children who had phonological and articulation disorders. It now includes children with dysarthria and CAS (two motor speech disorders). SLPs differentiate these disorders in order to make sound oral sensory-motor assessment and treatment decisions.
A phonological disorder can be defined as "a subset of sound production disorders in which linguistic and cognitive factors are thought to be central to the observed difficulties" (Strand, 2010, p. 4). "An articulation disorder is the atypical production of speech sounds characterized by substitutions, omissions, additions or distortions that may interfere with intelligibility" (ASHA, 1993b). Childhood dysarthria and apraxia of speech are motor speech disorders. Dysarthria "is a collective term for a group of related motor speech disorders resulting from disturbed muscular control of the speech mechanism" (Strand, 2010, p. 5). Childhood apraxia of speech (CAS) is currently defined as "a neurological childhood (pediatric) speech sound disorder, in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits" such as abnormal reflexes and muscle tone (ASHA, 2007a, p. 6).
Consider Figure 3 ("A Simplified Conceptual Model of the Components Involved in Oral Sensory-Motor Treatment") relative to childhood dysarthria and CAS. Childhood dysarthria involves problems with muscle tone/function that can negatively impact motor plans/gestures. CAS involves the motor plans/gestures themselves. Children with dysarthria may benefit from activities that improve muscle tone/function, and many authors have agreed on this point.35 Children with CAS do not need activities to improve muscle tone/function unless they exhibit concurrent muscle tone/function concerns.
However, few children seem to have CAS in isolation. Many have co-occurring childhood dysarthria and other disorders (Hammer, 2007; Strand 2010). Therefore, muscle tone/function may need to be addressed prior to (or in addition to) motor planning/gestures in those children with concomitant muscle function concerns. The oral mechanism exam (in conjunction with speech production tests and behavioral observations) assists SLPs in determining the predominance of speech motor planning/gesture impairment vs. speech muscle function impairment vs. auditory and/or language-based speech disorder. Based on such assessment, appropriate treatment choices can be made. SLP treatment choices will vary based on the type of disorder and individual patient/client needs.
Relevant Speech Motor Programming Research
In an article on the use of NSOMEs in pediatric speech treatment (the apparent topic of the "oral motor treatment" debate), Watson and Lof (2008, p. 339) said,
A great deal of information is available to help clinicians understand the principles of motor speech learning and control, and how to apply those principles to clinical practice.... The results of many investigations have documented the difference between the...movement for speech and nonspeech tasks.
These authors were likely speaking of the body of research by C. Moore and his colleagues who continue to study oral movement via electromyography (Steeve, Moore, Green, Reilly, & McMurtrey, 2008; Steve & Moore, 2009). Moore and his colleagues repeatedly demonstrated that the neural mechanisms controlling speech are likely to be different from those controlling eating and drinking, particularly beyond the age of 2 years (Moore, Smith, & Ringel, 1988; Moore & Ruark, 1996; Ruark & Moore, 1997; Green, Moore, Ruark, Rodda, Morvee, & VanWitzenburg, 1997).
While Moore and his colleagues mostly compared feeding and speech behaviors, the following hypothesis is also probable: If feeding motor plans/gestures are unique from speech motor plans/gestures, then motor plans/gestures for nonspeech oral sensory-motor activities are likely to be unique from speech motor plans/gestures. Therefore, motor plans/gestures taught for each activity should be specific to that activity when possible (e.g., the action of licking the lips is specific to feeding, not speech). Yet, sometimes an activity is chosen as a successive approximation toward a target goal when a desired motor outcome cannot be otherwise attained (Bahr & Rosenfeld-Johnson, 2010). For example, blowing may help a client learn to direct air through the mouth (instead of the nose); voicing and speech oral movements are added as soon as possible to attain speech.
The Long-Standing Discussion on the Treatment of Phonological vs. Motor Speech Disorders
While indications were subtle, the "oral motor treatment" controversy seemed in some way related to a long-standing discussion on the treatment of phonological vs. motor speech disorders. Most of the outspoken opponents in the "oral motor treatment" controversy appeared to have expertise in phonological disorders and/or cleft palate (e.g., C. Bowen, A. Kamhi, G. Lof, N. Lass, M. Pannbacker, D. Ruscello).36 Yet, most of those actually named in the controversy (Part II, Table 1; Bahr, 2011b) had expertise in oral sensory-motor disorders (e.g., motor speech, feeding, orofacial myofunctional, etc.).
The "oral motor treatment" controversy originally seemed to surround the use of NSOMTs37 and NSOMEs38 in the treatment of typically developing children with articulation and phonological disorders (Parts I & II; Bahr, 2011 a & b). Children with motor speech disorders (i.e., childhood dysarthria and CAS) did not appear to be part of the original discussion. These populations were eventually discussed (relative to NSOME) by Clark (2008), McCauley and Strand (2008b), and McCauley, et al. (2009).
An article by Muttiah, Georges, and Brackenbury (2011) also indicated that the "oral motor treatment" controversy was related to the discussion of phonological disorders. These authors compared the perceptions of 11 clinicians (who used NSOMTs) with 11 "child phonology" researchers (p. 47), not motor speech researchers.39 The clinicians treated an average of 47 percent of children with articulation or phonological disorders; they also treated children with motor speech disorders. Muttiah, et al. found that both clinicians and "child phonology" researchers "applied features of EBP toward NSOMTs," "were aware that others had different views," and based "their final decision" on "their experiences and work environment" (p. 58). Therefore, phonology researchers and clinicians likely used different frameworks when approaching the information on the use of NSOMTs, which led to different conclusions by each group.
Additionally, Kamhi (an expert in phonology) discussed trends in SLP treatment. He indicated a trend away from language-based speech treatment and toward motor speech treatment. He said (2005, p. 226),
What has occurred in the early 1990s to the present is the pendulum seems to have swung back to the motor side after spending 10-15 years on the side of language-based phonology. This is seen in the heightened interest in oral-motor approaches and the increasing number of children diagnosed with DAS [developmental apraxia of speech].
The trends observed by Kamhi may reflect consumer needs (an important aspect of EBP). According to ASHA demographics (2007b), 64 percent of certified SLPs treated "motor speech disorders." In addition, 62 percent of certified SLPs treated "autism/pervasive developmental disorder" and 58 percent treated "mental retardation/developmental disability" (two disorders that frequently co-occur with motor speech disorders).
The "oral motor treatment" debate has been multifaceted, extremely complex, and very uncomfortable for SLPs. It has been complicated by inaccurate general statements, definition and terminology problems, potential underlying agendas, and other factors. In particular, the topic of EBP seemed to be a point of contention between academics and clinicians throughout the debate. Academics (speaking and writing about the controversy) seemed most concerned about the availability of "best current evidence," while clinicians seemed most concerned about value being placed on their "clinical expertise."
Muttiah, et al. (2011) commented on the "oral motor treatment" debate relative to EBP. They said,
If we are to progress in this area [EBP], we need to be respectful and considerate of the research evidence as it currently exists, the successes and failures that clinicians have experienced, and the experiences and viewpoints of our clients. All of these pieces of information should be considered within the alternative frameworks that different professionals and clients might bring to the topic. By doing so, we can have informed discussions that may help us work through these disagreements.
Resolutions for the "oral-motor treatment" controversy were explored relative to EBP in Part III. Suggested models for collaborative research and coordinated training resulted. Collaborative research (where academics and clinicians combine their efforts and talents) would likely generate greatly needed "best current evidence" (one aspect of EBP). Coordinated training processes from undergraduate through continuing education would provide clinicians with essential knowledge to make appropriate clinical decisions and better serve SLP consumers (the two other aspects of EBP).
In a January 2011 interview, Dr. Paul R. Rao (ASHA President) reminded the SLP community of the famous words, "United we stand, divided we fall." He also said, "We need to keep our eyes on client/patient care as the keystone of our practice; once we realize our work is not about us but about those we serve, our personal concern will take a back seat and we can see the power of our discipline" (Moore, p. 20). While Dr. Rao was not specifically discussing the "oral motor treatment" debate, his words were practical advice for those involved in the controversy.
Here are a few other practical lessons from the debate:
- General statements are often inaccurate. Specificity is needed when describing populations and treatments under discussion.
- Criticism of others' ideas/experiences/work and "taking" sides (when the complete truth is unknown) is likely to escalate problems and decrease opportunities for discussion and resolution.
- It is unlikely that those with strong biases will readily change their opinions. However, sharing and discussing cases, ideas, and concerns may help apparent opponents find common ground from which to work.40
- Showing respect for colleagues and openly discussing differences is likely to reveal that each side of a debate/controversy has important information that may lead to a complete discussion of the topic, new ideas to explore, and advancement of the field.
- Insufficient empirical evidence to support or refute treatments does not mean they are ineffective. It demonstrates the need for empirical treatment research (one aspect of EBP) to support clinical decision-making. Hand washing is a famous example. Prominent physicians (Holmes and Semmelweiss) suggested that doctors were passing disease from patient to patient in the mid-1800s. However, most physicians did not begin to use hand-washing procedures until Lister and Pasteur proved the theory (Kihlstrom, 2000).
The "oral motor treatment" controversy resulted in significant confusion, misunderstanding, and disharmony within the SLP field. Powell said there was "an urgent need for some degree of consensus" (2008a, p. 274) regarding the debate. Much professional time and effort have been spent on the theoretical discussion of one very narrow aspect of SLP practice (i.e., the use of nonspeech oral exercises/activities in the treatment of children with speech disorders). With so many SLPs treating children with speech disorders, well-designed research projects that focus on specific speech treatments (e.g., "bottom-up," "hierarchical," "auditory-visual," "tactile-proprioceptive," etc.) and populations (e.g., CAS, childhood dysarthria, articulation disorders, phonological disorders, etc.) are essential. Evidence-based assessment and treatment materials have the potential to evolve from such empirical research.
Many SLPs participated in the surveys, data compilation, and feedback for this article. The masked peer-reviewers donated their time independent of the OMI.
Declarations of Interest
Diane Bahr co-owns Ages and Stages, LLC (a continuing education company and private practice) in Las Vegas, NV. She voluntarily co-chairs the OMI study group. She has authored two books: Nobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development (Sensory World, 2010) and Oral Motor Assessment and Treatment: Ages and Stages (Allyn & Bacon, 2001).
Rhonda J. Banford is the owner of Tip of the Tongue Speech and Language, LLC (a private practice) in Ballwin, MO. She collated and summarized the data collected via the "Survey for Future Research" (Appendix C). In addition to being the co-author of Part III, she edited the entire three-part series on the "oral motor treatment" debate.
Individuals participating in the surveys, data compilation, article review, and writing of this article series received no remuneration. Rhonda J. Banford, M.A.T., CCC-SLP and Maigen Bundy, M. Cl. Sc., Reg. CASLPO voluntarily edited and provided feedback (independent of the OMI) for the series. The OMI is an all-volunteer study group and does not advertise or endorse particular groups or individuals. The OMI website is donated by Marshalla Speech and Language.
Diane Bahr, MS, CCC-SLP, CIMI is a certified speech-language pathologist and infant massage instructor in private practice in Las Vegas, NV. She has practiced speech-language pathology since 1980 and has been a feeding therapist since 1983. Her experiences include teaching graduate, undergraduate, and continuing education courses; working with children and adults who exhibit a variety of speech, language, feeding, and swallowing disorders; and publishing/presenting (e.g., ASHA, 2008 & 2009) information on oral motor function, assessment, and treatment. She has taught university and/or continuing education courses on the topics of neurology, childhood language and reading disorders, adult disorders, and augmentative communication as well as feeding, motor speech, and mouth function. Email questions and comments regarding this article series to email@example.com.
Rhonda J. Banford, M.A.T., CCC-SLP is a certified speech-language pathologist and early childhood special educator in private practice in Ballwin, MO. She is currently working toward certification in the area of orofacial myology. She started her career as a self-contained classroom teacher for children with severe language and speech disorders. Over her many years as a speech-language pathologist, she has worked as a diagnostician, clinician, home health therapist, and school therapist. While working for her local school district, she designed and implemented a successful intensive speech classroom program for unintelligible preschoolers. Many of her students demonstrated childhood apraxia of speech and related disorders. She continues to provide similar services to private clients in the form of a camp program in the summer months. She can be reached at firstname.lastname@example.org.
- Agency for Healthcare Research and Quality. (2002a). Rating the strength of scientific research findings. AHRQ Publication No. 02-P022. Rockville, MD: Agency for Healthcare Research and Quality. Available from www.ahrq.gov/clinic/epcsums/strenfact.htm.
- Agency for Healthcare Research and Quality. (2002b). Systems to rate the strength of scientific evidence. Summary, evidence report/technology assessment: Number 47. AHRQ Publication No. 02-E015. Rockville, MD: Agency for Healthcare Research and Quality. Available from www.ahrq.gov/clinic/epcsums/strengthsum.htm.
- Alexander, R., Boehm, R., & Cupps, B. (1993). Normal development of functional motor skills: The first year of life. Tucson, AZ: Therapy Skill Builders.
- American Psychological Association (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: American Psychological Association.
- American Speech-Language-Hearing Association (1991). The role of the speech-language pathologist in management of oral myofunctional disorders, ASHA, 33 (Suppl. 5), 7.
- American Speech-Language-Hearing Association (1993a). Orofacial myofunctional disorders: Knowledge and skills, ASHA, 35 (Suppl. 10), 21-23.
- American Speech-Language-Hearing Association (1993b). Definitions of Communication Disorders and Variations [Relevant Paper]. Available from www.asha.org/policy.
- American Speech-Language-Hearing Association (2004). Evidence-Based Practice in Communication Disorders: An Introduction [Technical Report]. Available from www.asha.org/policy
- American Speech-Language-Hearing Association. (Year-end 2006). Annual Counts of the ASHA Membership and Affiliation. [ASHA's Surveys and Information Team].
- American Speech-Language-Hearing Association. (2007a). Childhood Apraxia of Speech [Technical Report]. Available from www.asha.org/policy.
- American Speech-Language-Hearing Association. (2007b). 2008 ASHA Marketing Planner. Obtained from www.asha.org.
- American Speech-Language-Hearing Association (2009). 2009 SLP Healthcare Survey. Available from www.asha.org/research/memberdata/HealthcareSurvey09.htm.
- American Speech-Language-Hearing Association. (2010a). 2010 Schools Survey-SLP Caseload Characteristics Report. Available from www.asha.org/uploadedFiles/Schools10Caseload.pdf.
- American Speech-Language-Hearing Association (2010b). Code of Ethics [Ethics]. Available from www.asha.org/policy.
- American Speech-Language-Hearing Association. (n.d.-a). Strategic Pathway to Excellence. Retrieved March 24, 2009 from http://www.asha.org.
- American Speech-Language-Hearing Association. (n.d.-b). Introduction to Evidence-Based Practice. Retrieved May 27, 2011 from http://www.asha.org/members/ebp/intro.htm.
- American Speech-Language-Hearing Association. (n.d.-c). ASHA's 2009-2010 Academic Year State-by-State Data on Graduate Education in Communication Sciences and Disorders. Retrieved May 28, 2011 from www.asha.org/academic/HES/HESDataReports.htm.
- American Speech-Language-Hearing Association (n.d.-d). Curriculum Resources. Retrieved September 16, 2011 from www.asha.org/academic/curriculum.
- Arvedson, J., Clark, H., Lazarus, C., Schooling, T., & Frymark, T. (2010a, November). Evidence-Based systematic review: The effects of oral motor interventions on feeding and swallowing in preterm infants. American Journal of Speech-Language Pathology, 19, 321-340.
- Arvedson, J., Clark, H., Lazarus, C., Schooling, T., & Frymark, T. (2010b, November). The effects of oral-motor exercises on swallowing in children: An evidence-based systematic review. Developmental Medicine & Child Neurology, 52(11). 1000-1013.
- Ashford, J., McCabe, D., Wheeler-Hegland, K., Frymark, T., Mullen, R., Musson, N., Schooling, T., & Hammond, C. S. (2009). Evidence-Based systematic review: Oropharyngeal dysphagia behavioral treatments. Part III - Impact of dysphagia treatments on populations with neurological disorders. Journal of Rehabilitation Research & Development, 46(2), 195-204.
- Bahr, D. C. (2001). Oral motor assessment and treatment: Ages and stages. Boston, MA: Allyn & Bacon.
- Bahr, D. (2008a). A topical bibliography on oral motor assessment and treatment. Oral Motor Institute, 2(1). Retrieved October 30, 2010 from www.oralmotorinstitute.org/mons/v2n1_bahr.html.
- Bahr, D. (2008b, November). The oral motor debate: Where do we go from here? Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Chicago, IL. (Full handout available from http://convention.asha.org/handouts/1420_2054 Bahr_Diane_124883_Nov03_2008_Time_103047AM.doc)
- Bahr, D. (2011a). The oral motor debate part I: Understanding the problem. Oral Motor Institute 3(1). Available from www.oralmotorinstitute.org.
- Bahr, D. (2011b). The oral motor debate part 2: Exploring terminology and practice patterns. Oral Motor Institute 3(2). Available from www.oralmotorinstitute.org.
- Bahr, D., & Rosenfeld-Johnson, S. (2010, February). Treatment of children with speech oral placement disorders (OPDs): A paradigm emerges. Communication Disorders Quarterly, 31, 131-138.
- Bunton, K. (2008). Speech versus nonspeech: Different tasks, different neural organization. Seminars in Speech and Language, 29, 267-275.
- Caruso, A. J., & Strand, E. A. (1999). Motor speech disorders in children: Definitions, background, and a theoretical framework. In A. J. Caruso and E. A. Strand (Eds.). Clinical management of motor speech disorders in children. New York: Thieme, 1-27.
- Clark, H. M. (2003). Neuromuscular treatments for speech and swallowing: A tutorial. American Journal of Speech-Language Pathology, 12, 400-415.
- Clark, H. M. (2008). The role of strength training in speech sound disorders. Seminars in Speech and Language, 29, 276-283.
- Clark, H., Lazarus, C., Arvedson, J., Schooling, T., & Frymark, T. (2009, November). Evidence-Based systematic review: Effects of neuromuscular electrical stimulation on swallowing and neural activation. American Journal of Speech-Language Pathology, 18(4), 361-375.
- Davis, B., & Velleman, S. (2008). Establishing a basic speech repertoire without using NSOME: Means, motive, and opportunity. Seminars in Speech and Language, 29, 312-319.
- Duffy, J. R. (1995). Motor speech disorders: Substrates, differential diagnosis, and management. St. Louis: Mosby Year Book.
- Forrest, K., & Iuzzini, J. (2008). A comparison of oral motor and production training for children with speech sound disorders. Seminars in Speech and Language, 29, 304-311.
- Frymark, T., Schooling, T., Mullen, R., Wheeler-Hegland, K., Ashford, J., McCabe, D., Musson, N., & Hammond, C. S. (2009). Evidence-Based systematic review: Oropharyngeal dysphagia behavioral treatments. Part I - Background and methodology. Journal of Rehabilitation Research & Development, 46(2), 175-184.
- Green, J. R., Moore, C. A., Ruark, J. L., Rodda, P. R., Morvee, W. T., & VanWitzenburg, M. J. (1997). Development of chewing in children from 12 to 48 months: Longitudinal study of EMG patterns. Journal of Neurophysiology, 77, 2704-2716.
- Hammer, D. (2007). Childhood apraxia of speech: New perspectives on assessment and treatment. Workshop presented in Las Vegas, NV: The Childhood Apraxia of Speech Association.
- Hayden, D. A. (2006). The PROMPT model: Use and application for children with mixed phonological-motor impairment. Advances in Speech-Language Pathology, 8(3), 265-281.
- Hayden, D. A. (2004). PROMPT: A tactually grounded treatment approach to speech production disorders. In I. Stockman (Ed.), Movement and action in learning and development: Clinical implications for pervasive developmental disorders (pp. 255-297). San Diego: Elsevier-Academic Press.
- Hayden, D., & Square, P. (1999). Verbal motor production assessment for children. San Antonio, TX: The Psychological Corporation.
- Hillis, A. E., & Bahr, D. C. (2001). Neurological and anatomical bases. In D. C. Bahr. Oral motor assessment and treatment: Ages and stages. Boston, MA: Allyn & Bacon.
- Justice, L. M., & Fey, M. E. (2004, September 21). Evidence-Based practice in schools: Integrating craft and theory with science and data. The ASHA Leader, [Electronic version]. Retrieved February 25, 2011, from http://www.asha.org/Publications/leader/2004/040921/f040921a.htm.
- Justice, L. M., Nye, C., Schwarz, J., McGinty, A., & Rivera, A. (2008). Methodological quality of intervention research in speech-language pathology: Analysis of ten years of group design studies. Evidence-Based Communication Assessment and Intervention, 2, 46-59.
- Kamhi, A. G. (2005). Summary, reflections, and future directions. In A. G. Kamhi and K. E. Pollock (Eds.). Phonological disorders in children: Clinical decision making in assessment and intervention. Baltimore: Paul H. Brooks Publishing Company, 211-228.
- Kamhi, A. G. (2008). A meme's-eye view of nonspeech oral-motor exercises. Seminars in Speech and Language, 29, 331-338.
- Kihlstrom, J. F. (2000). Doctors are reminded: Wash up! Institute for the Study of Healthcare Organizations & Transactions. Retrieved March 12, 2011 from www.institute-shot.com/hand_washing_by_health_care_providers.htm.
- Lass, N. J., & Pannbacker, M. (2008, July). The application of evidence-based practice to nonspeech oral motor treatments. Language, Speech, and Hearing Services in Schools, 39, 408-421.
- Lass, N., Pannbacker, M., Carroll, A., & Fox, J. (2006, November). Speech-language pathologists' use of oral motor treatment. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Miami, FL.
- Lof, G. L. (2003). Oral motor exercises and treatment outcomes. Perspectives on Language Learning and Education, 10, 7-11.
- Lof, G. L. (2006, November). Logic, theory and evidence against the use of non-speech oral motor exercises to change speech sound productions. Session presented at the annual meeting of the American Speech-Language-Hearing Association, Miami Beach, FL.
- Lof, G. L. (2007, November). Reasons why non-speech oral motor exercises should not be used for speech sound disorders. Session presented at the annual meeting of the American Speech-Language-Hearing Association, Boston, MA.
- Lof, G. L. (2008a, November). Evidence-Driven speech sound intervention: Alternatives to nonspeech motor exercises. Session presented at the annual meeting of the American Speech-Language-Hearing Association, Chicago, IL.
- Lof, G. L. (2008b). Introduction: Controversies surrounding nonspeech oral motor exercises for childhood speech disorders. Seminars in Speech and Language, 29, 253-256.
- Lof. G. L. (2009, November). Nonspeech oral motor exercises: An update on the controversy. Session presented at the annual meeting of the American Speech-Language-Hearing Association, New Orleans, LA.
- Lof, G. L., & Watson, M. (2005, November). Survey of universities' teaching: Oral motor exercises & other procedures. Session presented at the annual meeting of the American Speech-Language-Hearing Association, San Diego, CA.
- Lof, G. L., & Watson, M. (2008, July). A nationwide survey of nonspeech oral motor exercise use: Implications for evidence-based practice. Language, Speech, and Hearing Services in Schools, 39, 392-407.
- Lohr, K. N. (2004). Rating the strength of scientific evidence: Relevance for quality improvement programs. International Journal for Quality in Health Care, 16(1): 9-18.
- Maas, E., Robin, D. A., Austermann Hula, S. N., Freedman, S. E., Wulf, G., Ballard, K., & Schmidt, R. A. (2008). Principles of motor learning in treatment of motor speech disorders. American Journal of Speech-Language Pathology, 17(3), 277-298.
- McCabe, D., Ashford, J., Wheeler-Hegland, K., Frymark, T., Mullen, R., Musson, N., Hammond, C. S., & Schooling, T. (2009). Evidence-Based systematic review: Oropharyngeal dysphagia behavioral treatments. Part IV - Impact of dysphagia treatment on individuals' postcancer treatments. Journal of Rehabilitation Research & Development, 46(2), 205-214.
- McCauley, R. J., & Strand, E. A. (2008a). A review of standardized tests of nonverbal oral and speech motor performance in children. American Journal of Speech-Language Pathology, 17, 81-91.
- McCauley, R. J., & Strand, E. A. (2008b). Treatment of childhood apraxia of speech: Clinical decision making in the use of nonspeech oral motor exercises. Seminars in Speech and Language, 29, 284-293.
- McCauley, R. J., Strand, E., Lof, G. L., Schooling, T., & Frymark, T. (2009, November). Evidence-Based systematic review: Effects of nonspeech oral motor exercises on speech. American Journal of Speech-Language Pathology, 18(4), 343-360.
- McNeilly, L. (2010, November 23). ASHA will roll out associates program in 2011. The ASHA Leader, 15(14), 7.
- Moore, C. A., Smith, A., & Ringel, R. L. (1988). Task-specific organization of activity in human jaw muscles. Journal of Speech and Hearing Research, 31, 670-680.
- Moore, C. A., & Ruark, J. L. (1996). Does speech emerge from earlier appearing oral motor behaviors? Journal of Speech and Hearing Research, 39, 1034-1047.
- Moore, M. (2011, January 18). "ASHA rocks" - and so does Paul R. Rao. The ASHA Leader, 16(1), 20-23.
- Morris, S. E. (1989). Development of oral-motor skills in the neurologically impaired child receiving non-oral feedings. Dysphagia, 3(3). 135-154.
- Mullen, R. (2006, December). Conducting a systematic review of the research literature. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 15(4), 15-19.
- Muttiah, N., Georges, K., & Brackenbury, T. (2011, February). Clinical and research perspectives on nonspeech oral motor treatments and evidence-based practice. American Journal of Speech-Language Pathology, 20, 47-59.
- Pannbacker, M., & Lass, N. (2002, November). The use of oral motor therapy in speech-language pathology. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Atlanta, GA.
- Pannbacker, M., & Lass, N. (2003, November). Effectiveness of oral motor treatment in Slp. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Chicago, IL.
- Pannbacker, M., & Lass, N. (2004, November). Ethical issues in oral motor treatment. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Philadelphia, PA.
- Pierce, R., & Taylor, P. (2001). Rationale for including orofacial myofunctional therapy in university training programs. International Journal of Orofacial Myology, 28, 24-32.
- Rao, P. R. (2011, March). Special interest groups: An integral part of our ASHA family. The ASHA Leader, 16(3), 23.
- Rao, P. R. (2011, June 7). Evidence-Based practice: The coin of the realm in CSD. The ASHA Leader, 16(7), 7.
- Rao, P. R. (2011, August 30). From the president: Mentorship: The price of membership. The ASHA Leader, [Electronic Version]. Retrieved October 5, 2011 from www.asha.org/Publications/leader/2011.
- Robey, R. R. (2004, April 13). Levels of evidence. The ASHA Leader, [Electronic Version]. Retrieved February 19, 2011 from www.asha.org/Publications/leader/2004.
- Robey, R. R., & Dalebout, S. D. (1998, December). A tutorial on conducting meta-analyses of clinical outcome research. Journal of Speech, Language, and Hearing Research, 41, 1227-1241.
- Ruscello, D. M. (2008). An examination of nonspeech oral motor exercises for children with velopharyngeal inadequacy. Seminars in Speech and Language, 29, 294-303.
- Ruark, J. L., & Moore, C. A. (1997). Coordination of lip muscle activity by 2-year-old children during speech and nonspeech tasks. Journal of Speech, Language, and Hearing Research, 40, 1373-1385.
- Scottish Intercollegiate Guidelines Network. (2002). Glossary of key terms. Available at www.sign.ac.uk.
- Scott, K. S., Bahr, D., & Reardon-Reeves, N. (2009, November). Creating effective and efficient research teams. Session presented at the annual meeting of the American Speech-Language-Hearing Association, New Orleans, LA (Full handout available from www.asha.org/Events/convention/handouts/2009/1926_Scaler_Scott_Kathleen.htm.)
- Steeve, R. W., & Moore, C. A. (2009). Mandibular motor control during early development of speech and nonspeech behaviors. Journal of Speech, Language, and Hearing Research, 52, 1530-1554.
- Steeve, R. W., Moore, C. A., Green, J. R., Reilly, K. J., & McMurtrey, J. R. (2008, December). Babbling, chewing, and sucking: Oromandibular coordination at 9 months. Journal of Speech, Language, and Hearing Research, 51, 1390-1404.
- Strand, E., Stoeckel, R., & Baas, B. (2006). Treatment of severe childhood apraxia of speech: A treatment efficacy study. Journal of Medical Speech Pathology, 14, 297-307.
- Strand, E. A. (2010). Differential diagnosis and treatment of childhood apraxia of speech. Workshop presented in Las Vegas, NV: The Childhood Apraxia of Speech Association.
- United States Department of Labor. (2010). Occupational Outlook Handbook, 2010-11 Edition, Speech-Language Pathology. Bureau of Labor Statistics (Available from http://www.bls.gov/oco/ocos099.htm#empty).
- Watson, M. M., & Lof, G. L. (2008). Epilogue: What we know about nonspeech oral motor exercises. Seminars in Speech and Language, 29, 339-344.
- Wheeler-Hegland, K., Ashford, J., Frymark, T., McCabe, D., Mullen, R., Musson, N., Hammond, C. S., & Schooling, T. (2009). Evidence-Based systematic review: Oropharyngeal dysphagia behavioral treatments. Part II - Impact of dysphagia treatment on normal swallow function. Journal of Rehabilitation Research & Development, 46(2), 185-194.
- Wheeler-Hegland, K., Frymark, T., Schooling, T., McCabe, D., Ashford, J., Mullen, R., Hammond, C. S., & Musson, N. (2009). Evidence-Based systematic review: Oropharyngeal dysphagia behavioral treatments. Part V - Applications for clinicians and researchers. Journal of Rehabilitation Research & Development, 46(2), 215-222.
- Wilson, E. M., Green, J. R., Yunusova, Y., & Moore, C. A. (2008). Task specificity in early oral motor development. Seminars in Speech and Language, 29, 257-266.
- Woolf, H. B. (Ed.). (1980). Webster's new collegiate dictionary. Springfield, MA: G. & C. Merriam Company.
|ARTICLE TITLES AND AUTHORS BY TOPIC AND DATE||TYPE OF EVIDENCE||PURPOSE||SOME PERTINENT OUTCOMES|
|Evidence-Based Systematic Review: Effects of Nonspeech Oral Motor Exercises on Speech (McCauley, Strand, Lof, Schooling, & Frymark, November 2009)||Evidence-Based Systematic Review (EBSR) of the Research Literature||"...to examine the current evidence for the use of oral motor exercises (OMEs) on speech (i.e., speech physiology, speech production, and functional speech outcomes) as a means of supporting further research and clinicians' use of evidence-based practice " (p. 343)||"Insufficient evidence to support or refute the use of OMEs [oral motor exercises] to produce effects on speech...." (p. 343)|
|Swallowing (Including Oral Phase)|
|Evidence-Based Systematic Review: Oropharyngeal Dysphagia Behavioral Treatments. Part I - Background and Methodology (Frymark, Schooling, Mullen, Wheeler-Hegland, Ashford, McCabe, Musson, & Hammond, 2009)||3 EBSRs in a 5-part series||To examine the evidence for the use of compensatory postures and maneuvers (i.e., "movement of the oral, pharyngeal, or laryngeal structure before or during the pharyngeal phase of the swallow that are intended to increase swallow force or alter airway protection...") in swallowing treatment (p. 178)||"...overview of the levels-of-evidence scheme used by... ASHA to conduct systematic reviews" (p. 175)|
|Evidence-Based Systematic Review: Oropharyngeal Dysphagia Behavioral Treatments. Part II - Impact of Dysphagia Treatment on Normal Swallow Function (Wheeler-Hegland, Ashford, Frymark, McCabe, Mullen, Musson, Hammond, & Schooling, 2009)||3 EBSRs in a 5-part series||Part II: See previous description||"For non-disordered populations, the existing evidence demonstrates differential effects of postural changes and maneuvers on swallowing physiology" (p. 185).|
|Evidence-Based Systematic Review: Oropharyngeal Dysphagia Behavioral Treatments. Part III - Impact of Dysphagia Treatments on Populations with Neurological Disorders (Ashford, McCabe, Wheeler-Hegland, Frymark, Mullen, Musson, Schooling, & Hammond, 2009)||3 EBSRs in a 5-part series||Part III: See previous description||"...limited evidence from seven studies shows the potential effects of dysphagia behavioral interventions for select groups of individuals with neurologically induced dysphagia" (p. 195).|
|Evidence-Based Systematic Review: Oropharyngeal Dysphagia Behavioral Treatments. Part IV - Impact of Dysphagia Treatment on Individuals' Postcancer Treatments (McCabe, Ashford, Wheeler-Hegland, Frymark, Mullen, Musson, Hammond, & Schooling, 2009)||3 EBSRs in a 5-part series||Part IV: See previous description||"...limited evidence exists from six studies showing the positive effects of behavioral swallowing interventions for populations with structural disorder" (p. 205).|
|Evidence-Based Systematic Review: Oropharyngeal Dysphagia Behavioral Treatments. Part V - Applications for Clinicians and Researchers (Wheeler-Hegland, Frymark, Schooling, McCabe, Ashford, Mullen, Hammond, & Musson, 2009)||3 EBSRs in a 5-part series||Part V: See previous description||"...how speech-language pathologists treating individuals with oropharyngeal dysphagia can incorporate EBP into their clinical decision-making process" (p. 215)|
|Evidence-Based Systematic Review: Effects of Neuromuscular Electrical Stimulation [NMES] on Swallowing and Neural Activation (Clark, Lazarus, Arvedson, Schooling, & Frymark, November 2009)||EBSR||"To systematically review the literature examining the effects of neuromuscular electrical stimulation (NMES) on swallowing and neural activation. The review was conducted as part of a series examining the effects of oral motor exercises (OMEs) on speech, swallowing, and neural activation" (p. 361).||"Surface NMES to the neck has been most extensively studied with promising findings, yet high-quality controlled trials are needed to provide evidence of efficacy.... Additional research is needed to document the effects of such protocols on swallowing performance" (p. 361).|
|Evidence-Based Systematic Review: The Effects of Oral Motor Interventions on Feeding and Swallowing in Preterm Infants (Arvedson, Clark, Lazarus, Schooling, & Frymark, November 2010a).||EBSR||"To conduct an evidence-based systematic review and provide an estimate of the effects of oral motor interventions (OMIs) on feeding/swallowing outcomes (both physiological and functional) and pulmonary health in preterm infants" (p. 321)||"Although some OMIs [oral motor interventions] show promise for enhancing feeding/swallowing in preterm infants, methodological limitations and variations in results across studies warrant careful consideration of their clinical use" (p. 321).|
|The Effects of Oral-Motor Exercises on Swallowing in Children: An Evidence-Based Systematic Review (Arvedson, Clark, Lazarus, Schooling, & Frymark, November 2010b)||EBSR||"To determine the state and quality of evidence on the effects of oral motor exercises (OME) on swallowing physiology, pulmonary health, functional swallowing outcomes, and drooling management in children with swallowing disorders" (p. 1000)||"There is insufficient evidence to determine the effects of OME on children with oral sensorimotor deficits and swallowing problems. Well-designed studies are needed..." (p. 1000).|
|ARTICLE TITLES AND AUTHORS||TYPE OF ARTICLE||TOPICS/POPULATIONS DISCUSSED||SOME PERTINENT OUTCOMES|
|Introduction: Controversies Surrounding Nonspeech Oral Motor Exercises for Childhood Speech Disorders (Lof, 2008b)||Theoretical Article: Combination of Literature Review, Theory, and Opinion||Introduction to article series on the use of NSOMEs for children with speech disorders||"NSOMEs can be defined as any therapy technique that does not require the child to produce a speech sound but is used to influence the development of speaking abilities" (p. 253).|
|Task Specificity in Early Oral Motor Development (Wilson, Green, Yunusova, & Moore, 2008)||Theoretical Article: Combination of Literature Review, Theory, and Opinion||Differences between speech and feeding behaviors in children||"Well-designed empirical studies are necessary...to establish the efficacy of NSOMEs for specific clinical populations and treatment targets" (p. 257).|
|Speech versus Nonspeech: Different Tasks, Different Neural Organization (Bunton, 2008)||Theoretical Article: Combination of Literature Review, Theory, and Opinion||Differences in neural organization for speech and nonspeech tasks (i.e., jaw, tongue, and lip activities) in children and adults||"...functional imaging studies document differences in activation patterns for speech compared with nonspeech oral motor tasks in neurologically healthy individuals" (p. 267).|
|The Role of Strength Training in Speech Sound Disorders (Clark, 2008)||Theoretical Article: Combination of Literature Review, Theory, and Opinion||Potential use of appropriate speech-based strengthening in children||"A much larger body of research is needed to determine the conditions under which strength training is most appropriately applied in the treatment of childhood speech disorders" (p. 276).|
|Treatment of Childhood Apraxia of Speech: Clinical Decision Making in the Use of Nonspeech Oral Motor Exercises (McCauley & Strand, 2008b)||Theoretical Article: Combination of Literature Review, Theory, and Opinion||Use of tactile-proprioceptive and gestural cueing in addition to auditory and visual cueing for children with childhood apraxia of speech (CAS)||"Given a virtual absence of relevant empirical evidence on the question of the value of NSOMEs for children with CAS, clinicians are urged to examine the soundness of theoretical rationales they turn to when making clinical decisions" (p. 284).|
|An Examination of Nonspeech Oral Motor Exercises for Children with Velopharyngeal Inadequacy (Ruscello, 2008)||Theoretical Article: Combination of Literature Review, Theory, and Opinion||The importance of task specific activities in children with velopharyngeal insufficiency||"There is... a small subset of clients who may improve with treatment using muscle rehabilitation procedures that are task specific to speech" (p. 294).|
|A Comparison of Oral Motor and Production Training for Children with Speech Sound Disorders (Forrest & Iuzzini, 2008)||Research Article||Ten subjects ages 3.3 to 3.6 years with normal hearing/oral structures and with speech sound disorders were compared using traditional treatment vs. NSOMEs||"Results demonstrated a statistically significant effect of treatment type with greater production gains with PT [traditional production treatment] compared with NSOMEs.... in the treatment of PAD [phonological/articulatory disorder]" (p. 304).|
|Establishing a Basic Speech Repertoire without Using NSOME: Means, Motive, and Opportunity (Davis & Velleman, 2008)||Theoretical Article: Combination of Literature Review, Theory, and Opinion||The interrelated nature of language and communication in the treatment of childhood speech disorders||"...nonspeech oral motor exercise (NSOME) protocols require decontextualized practice of repetitive nonspeech movements that are not related to functional communication.... No evidence from research literature on the course of speech and language acquisition suggests that this conceptualization is valid" (p. 312).|
|A Meme's-Eye View of Nonspeech Oral-Motor Exercises (Kamhi, 2008)||Theoretical Article: Combination of Literature Review, Theory, and Opinion||Possible reasons NSOMEs have become popular in the treatment of childhood speech disorders||"The ideas motivating the use of nonspeech oral motor exercises (NSOMEs) cluster into three memeplexes that reflect the rich history of oral motor and nonspeech activities in speech-language pathology; a bottom-up, discrete skill theory of learning; and common treatment practices.... There are so many reasons to use NSOMEs that the more interesting question may be why some clinicians (<15%) do not use these activities" (p. 331).|
|Epilogue: What We Know about Nonspeech Oral Motor Exercises (Watson & Lof, 2008)||Theoretical Article: Combination of Literature Review, Theory, and Opinion||Summary of article series on the use of NSOMEs for children with speech disorders||"A great deal of information is available to help clinicians understand the principles of motor speech learning and control, and how to apply those principles to clinical practice.... The results of many investigations have documented the difference between the...movement for speech and nonspeech tasks" (p. 339).|
Survey for Future Research:State of Residence:________
Diane Bahr, MS, CCC-SLPToday's Date:____________
Many specific questions regarding oral motor treatment became apparent from studying the likely root of the oral motor controversy, the "Survey on Oral Motor Treatment," and the review of oral motor journal literature.
Circle questions important to you. Write other questions you have.
- Would a clear definition of oral motor function and the many aspects of oral motor treatment (i.e., feeding/oral phase swallowing, motor speech, orofacial myofunctional treatment, oral awareness/discrimination, and oral activities/exercises) help researchers and clinicians use the terminology more accurately?
- How can SLPs become more cohesive as a profession? Could group-design research projects combining the efforts of researchers (often doctoral level SLPs) with SLPs who carry active caseloads (often master's level SLPs) be developed?
- What is being taught at the undergraduate and graduate levels on feeding, motor speech, and mouth function? Are students still being taught how to adequately conduct, interpret, and use the results of an oral examination?
- How can continuing education better meet the needs of working therapists? Is there a way to better coordinate undergraduate, graduate, and continuing education on the topic of oral motor assessment and treatment as well as other topics?
- Is there a professional interest in an updated text on oral motor assessment and treatment? Should researchers and practicing clinicians collaborate on this?
- Is there an appropriate place and use of nonspeech and/or nonfeeding oral treatments with appropriate populations? What is this place and use?
- What other related questions do you have?
1 Ages and Stages, LLC; Las Vegas, NV
2 Tip of the Tongue Speech and Language, LLC; Ballwin, MO
3 Academics are "member[s] of an institute of learning" (Woolf, 1980, p. 6).
4 "Narrow" is a descriptive term meaning "to decrease the scope or sphere of" (Woolf, 1980, p. 758).
5 The Oral Motor Institute (OMI) studies the "oral sensory and motor components of articulation, motor speech, and feeding development, disorders, assessment, and treatment." Retrieved October 30, 2010 from www.oralmotorinstitute.org/index.html. The all-volunteer OMI study group had over 1100 members as of February 24, 2011 (S. Marshalla, personal communication).
6 T. Schooling, personal communication; March 14, 2011.
7 Schooling, personal communication; March 14, 2011.
8 Robey and Dalebout (1998) described meta-analysis as "a mathematical synthesis of independent research findings scattered throughout a body of literature" (p. 1228).
9 LSHSS is ASHA's Language, Speech, and Hearing Services in Schools journal.
10 It may also be helpful to survey the populations this small percentage of SLPs treat. Do they treat children with phonological and articulation disorders, children with motor speech disorders, etc.?
11 Retrieved October 30, 2010 from www.oralmotorinstitute.org/index.html.
12 Most of the OMI board members are experienced master clinicians and 2 have PhDs.
13 One of the items listed by Lass and Pannbacker (2008, p. 416, Table 6) was Bahr's peer-reviewed textbook (Oral Motor Assessment and Treatment: Ages and Stages, 2001). The textbook covers a full range of oral sensory-motor assessment and treatment topics including anatomy, physiology, neurology, feeding, and motor speech. Another item listed was a clinical article "Development of Oral-Motor Skills in the Neurologically Impaired Child Receiving Non-Oral Feedings" by Suzanne Evans Morris (1989). These items did not appear to fit with the other items in the Lass and Pannbacker list.
14 "SPEECH-MOTOR ACTIVITY - any therapy activity involving the use of the oral musculature (e.g., lips,...mandible, cheeks, [and] velum) that INCLUDES the production of speech sounds at the same time" (P. Flipsen, personal communication, February 17, 2011).
15 "NSOMTs focus on nonspeech movements of the speech mechanism such as exercise, massage, blowing, positioning, icing, sucking, swallowing, cheek puffing, and other nonspeech activities" (Lass & Pannbacker, 2008, p. 411). Therefore, techniques incorporating speech sound production are not considered NSOMTs.
16 NSOMEs were defined as "any technique that does not require the child to produce a speech sound but is used to influence the development of speaking abilities" (Lof & Watson, 2008, p. 394). Therefore, techniques incorporating speech sound production are not considered NSOMEs.
17 Prompts for Restructuring Oral Muscular Phonetic Targets (Hayden, 2004, 2006)
18 Definitions listed and discussed in Part II (Bahr, 2011b).
19 AJSLP is AHSA's American Journal of Speech-Language Pathology.
20 JSLHR is ASHA's Journal of Speech, Language, and Hearing Research.
21 Dr. Paul R. Rao (2011 ASHA president) recently wrote about the importance of "mentorship" in the SLP field (August 30, 2011; ASHA Leader).
22 Oral Motor Assessment and Treatment: Ages and Stages (Bahr, 2001) seemed to be the only textbook covering the many aspects of oral sensory-motor assessment and treatment in one source.
23 Consumers are SLP students, clients, patients, and appropriate others.
24 A number of clinical textbooks have been recently published on motor speech and swallowing disorders. Recent tutorials (applicable to oral sensory motor assessment and treatment) were published by Clark (2003) and Maas, Robin, Austermann Hula, Freedman, Wulf, Ballard, and Schmidt (2008).
25 Dynamic Temporal and Tactile Cueing (DTTC) is a recent example of a motor speech intervention with an empirical evidence base (Strand, Stoeckel, & Bass, 2006). The Verbal Motor Production Assessment for Children (VMPAC, Hayden & Square, 1999) is a recent example of a pediatric, motor speech assessment with an empirical evidence base (as discussed by McCauley and Strand in 2008a). However, data is needed on SLPs' clinical experiences and the value patients and clients place on these techniques to complete the EBP requirements.
26 Available from www.asha.org/academic/curriculum (ASHA, n.d.-d); no motor speech curriculum resources were provided in this document.
27 ASHA's 2011 president Dr. Paul R. Rao (March 2011, p. 23) expressed the following benefits of SIGs which could apply to all training levels: "There is benefit in connecting with colleagues who share our interests and expertise, but we gain much more when we also use our collective knowledge to advance the goals and objectives of the entire organization."
28 Personal communications from E. Palumbo (October 30, 2011) and P. Taylor (October 29, 2011)
29 McNeilly (2010); L. McNeilly, personal communication (July 5, 2011)
30 ASHA's 2009-2010 Academic Year State-by-State Data on Graduate Education in Communication Sciences and Disorders revealed 266 SLP master's programs and 83 doctoral SLP programs in the USA (n.d.-c, p. 17, Retrieved May 28, 2011 from www.asha.org/academic/HES/HESDataReports.htm).
31 Normal Development of Functional Motor Skills: The First Year of Life (Alexander, Boehme, & Cupps, 1993) contains topics that may be taught in such a course.
32 Orofacial myofunctional treatment focuses on normal tongue resting posture and oral phase swallowing as well as related dental and speech concerns. ASHA (1991, 1993a) published official guidelines for this type of treatment.
33 The use of the terminology "motor plans/gestures" reflects recent discussions on motor learning theories (Bahr & Rosenfeld-Johnson, 2010).
34 Leslie Faye Davis; personal communication; July 15, 2011
35 See Part II (Bahr, 2011b).
36 Areas of expertise based on published information by these individuals.
37 "NSOMTs focus on nonspeech movements of the speech mechanism such as exercise, massage, blowing, positioning, icing, sucking, swallowing, cheek puffing, and other nonspeech activities" (Lass & Pannbacker, 2008, p. 411). Therefore, techniques incorporating speech sound production are not considered NSOMTs.
38 NSOMEs were defined as "any technique that does not require the child to produce a speech sound but is used to influence the development of speaking abilities" (Lof & Watson, 2008, p. 394). Therefore, techniques incorporating speech sound production are not considered NSOMEs.
39 Different outcomes may have been found if motor speech researchers were matched with clinicians treating mostly children with motor speech disorders and if phonology researchers were matched with clinicians treating mostly phonological disorders.
40 For example, D. Bahr and G. Lof were both instructors in SLP graduate training programs when Bahr wrote the textbook Oral Motor Assessment and Treatment: Ages and Stages (2001) and Lof began expressing his concerns regarding NSOME (2003). Both appeared to want parameters for the use of oral sensory-motor activities/exercises. This may have been common ground from which these two SLPs could have worked.
Please cite this article as:
Bahr, D., & Banford, R. J. (2012). The oral motor debate part III: Exploring research and training needs/ideas. Oral Motor Institute, 4(1). Available from www.oralmotorinstitute.org.
Permalink URL: www.oralmotorinstitute.org/mons/v4n1_bahr.html