RESEARCH NEEDS

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

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Movement and Articulation

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

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Type of Stimulation

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

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Developmental Data on Speech Movement

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

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

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Data on Incorrect Oral Movement Patterns

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

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Movement and Phonology

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

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PROPOSAL

twenty-two fundamental methods

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

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

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1. Assist Oral Movements

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

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• To assist tongue back elevation for /r/: "A flat stick or a small rod ... may be put under the tongue to push it back and up" (Scripture, 1912, p. 148).

• To assist lower lip elevation for /f/: "The trainer [uses the fingers and] moves the lower lip upward until it comes in contact with the curved edge of the upper teeth" (Hawk and Young, 1955, p. 16).

• To assist tongue tip elevation for lingua-alveolar phonemes: "Sometimes it is helpful to use a tongue depressor or a rounded stick to bring the tongue into the desired position" (Berry & Eisenson, 1956, p. 42).

• To assist jaw movement in swallowing: "Occasionally, the clinician may assist the patient's attempts at jaw movement by placing external pressure on the mandible in the desired direction of movement ... If any pain occurs, the exercise should be discontinued" (Logemann, 1983, p. 142).

• To assist jaw lowering for /ɑ/: "Pull down the chin with your index finger" (Kaufman, 2006, p. 14).

• To assist correct tongue placement for /θ/: (1.) "Instruct the student, 'Please stick out your tongue.' (2.) Once the tongue is out, gently close the student's mouth. If the tongue is sticking out too far, gently push it back with a tongue depressor" (Bleile, 2006, p. 23).

 

 

2. Associate Oral Movements

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

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• Associating tongue-back elevation for /ŋ/ with tongue tongue-back elevation for /g/: "The pupil [is] induced through imitation of /ŋ/ to prolong /ŋ/ at first and then to complete the sound with a sudden expulsion of the voice" (Nemoy & Davis, 1937, p. 116).

• Associating lingua-alveolar position for /t/ with lingua-alveolar position for /s/: "Make [t] ... Make [t] with strong aspiration on the release ... Prolong the strongly aspirated release ... Remove the tip of the tongue slowly during the release from the alveolar ridge to make a [ts] cluster ... Prolong the [s] part of the [ts] cluster in words like oats ... Practice prolonging the last portion of the [ts] production ... Practice 'sneaking up quietly' on the [s] (delete /t/) ... Produce [s]" (Bernthal & Bankson, 2004, p. 302).

• Associating tongue-tip protrusion for /θ/ with tongue tongue-tip elevation for /l/: "Instruct the client to say /θ/. Then tell the client to lower the jaw and draw the tongue tip backward until it contacts the alveolar ridge behind the upper teeth. While maintaining contact with the alveolar ridge, the client says /l/" (Secord et al, 2007, p. 90).

 

3. Contrast Oral Movements

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

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• Contrasting positions used to teach lip rounding for /w/: "Contrast lip spreading with lip rounding, and a large mouth opening with a small mouth opening" (Hanson, 1983, p. 206).

• Contrasting tongue positions used to eliminate a frontal lisp: "A great way to wake up the tip of the tongue and to get the tip behind the teeth is to have the client say, 'th-s-th-s-th-s-th-s' back and forth in one continuous air stream. This practice stimulates the tip of the tongue through tactile means as it rubs forward and back against the upper central incisors" (Marshalla, 2007, p. 104).

• Contrasting tongue tip and back positions used to learn /k/: "Have the client say /t/. The /t/ can be used to illustrate the build up of pressure and the quick release. Then have him attempt saying /t/ with the tongue tip behind the lower central incisors. Follow with the step of instructing the client to raise the back of the tongue up to the soft palate and attempt the /k/ production" (Secord et al, 2007, p. 31).

 

 

4. Cue Oral Movements

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

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• Visual and tactile cue for production of /st/: "The clinician may draw her finger up the child's bare arm while saying /s/ and tap it lightly as she releases the /t/, thus calling attention to the continuancy of /s/ and the quick burst of /t/" (Hodson & Paden, 1983, p. 51).

• Tactile cue for lingua-velar articulation: "Pressure applied well under the child's chin, upward and toward the base of the tongue, will reinforce back-of-tongue ... productions" (Blakely, 1983, p. 30).

• Verbal and visual cues to teach fricatives: "We had Clifford stick out his tongue and blow over the top of it to produce "th" or a close approximation of it. ... By providing additional cues regarding tongue, lip and teeth placement, fricative production can be shaped" (Mowrer, 1984, p. 96).

• Conceptual cue (the "angry cat") for production of /f/: "Make a loose contact between the upper front incisors and the lower lip and force the air stream between them to produce frication. Do not use voice. This is the angry cat sound. Hear the cat go 'f-f-f-f'" (Flowers, 2003, p.39).

• Hand signal cue for /m/: "Slide index finger across lips horizontally or place fingers directly over lips as in 'blowing a kiss'" (Kaufman, 2006, p. 20).

 

5. Describe Oral Movements

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

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• To describe lip position for /v/: "[The client] is told to bite his lower lip" (Scripture, 1912, p.124-125).

• To describe tongue position for /t/: "Discuss how this sound is produced, including how the tongue is positioned on the alveolar ridge" (Folk, 1992, p. 6).

• To describe tongue tip placement for lingua-alveolar phonemes: "See the tip of my tongue? I am going to make it real small like this. Then I am going to lift it up. See? Then the tip of my tongue is going to touch this part of my mouth. Did you see that? Can you do it?" (Hegde, 1998, p. 155).

• To describe lip position for /m/: "Carefully explain the production characteristics using diagrams or illustrations if possible (e.g., pointing out to the client the lip-to-lip posturing, and pointing out that the air will escape through the nose while making the humming sound /m/)" (Secord et al, 2007, p. 74).

 

6. Develop Sensory Awareness and Discrimination for Oral Movements

 

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

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• To develop general oral sensory awareness: "Learn to recognize the movement as part of some familiar biological movement such as chewing, swallowing, coughing ... chew in an exaggerated fashion ... practice licking the lips and cleaning the tongue and cheeks with the tongue" (Van Riper, 1954, pp. 216-218).

• To develop general oral sensory awareness and discrimination: "Provide many opportunities for the child to engage in generalized mouthing activities of the hands, simple environmental objects, and toys" (Morris & Klein, 2000, P. 411)

• To develop oral sensory awareness and discrimination: "Massage is completed on both the external and internal oral structures. Intraoral massage ... can increase intraoral awareness and has the potential to improve the child's responses to sensation in the oral area" (Bahr, 2001, p. 177).

• To develop sensory awareness of the lips: " 'Bite' the lips. First the upper and then the lower lips are 'sucked into' the slightly open rows of teeth ... 'Rub' both lips together. First right and left, then forward and backward" (Bauman-Waengler, 2004, p. 225)

• To develop sensory awareness and discrimination of the mouth: "Slightly dampen a non-flavored Toothette ... Massage [the client's] lips using a twisting motion. While continuing the twisting motion, work into his mouth via the buccal cavity on both sides. Progress to the surface and lateral margins of his tongue" (Rosenfeld-Johnson, 2005, p. 146).

 

7. Direct Oral Movements

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

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• To direct air stream for /s/: "Have the patient practice emitting expired breath streams thru [the] small hole ... of a hollow, rubber tube" (Borden & Busse, 1929, p. 184).

• To direct tongue tip elevation to the alveolar ridge for production of /l/: "Place thumb and middle finger in a flattened position on upper lip points 2. Press evenly while phonating" (Vaughn & Clark, 1979, p. 200).

• To direct tongue elevation for /ɚ/: "Tell the client you are going to pull on an imaginary string attached to the back of his head. As you pull the imaginary string up from the back of the client's head, instruct the client to lift the back of a tensed tongue and say /ɚ/" (Secord et al, 2007, p. 153).

 

8. Dissociate Oral Movements

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

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• To dissociate tongue movement from jaw movement for /t/: "The insertion of the broad side of a tongue depressor between the side teeth and holding it steady while repeating t, t, t, in rapid succession will assist in securing independent action of the tongue" (Nemoy & Davis, 1937, p. 90).

• To dissociate tongue tip from lip movement in production of /l/: "Retract the lips sharply, holding them back with the fingers if necessary, and ask the child to sing 'la-la-la'" (Berry & Eisenson, 1956, p. 151).

• To dissociate tongue movement from lip movement for /r/: "The lip retractor is a device designed for use by orthodontists for photographing the teeth. Placed correctly in the mouth, the lip retractor pulls the lips laterally. With the lip retractor in place, most clients will be unable to move the lips at all. This is a great way to help them focus on what their tongues should be doing" (Marshalla, 2004, p. 113).

 

9. Exaggerate Oral Movements

 

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

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• To exaggerate as a general articulation method: "When the correct sound has been produced ... the [client] should hold it, increasing its intensity, repeating it, whispering it, exaggerating it, and varying it in as many ways as possible without losing its identity. He should focus his attention on the 'feel' of the position in terms of tongue, palate, jaws, lips, and throat" (Van Riper, 1954, p. 239).

• To exaggerate in order to understand incorrect movements: "Encouraging exaggeration of the undesirable movement will make it more obvious to the child" (McDonald & Chance, 1964, p. 124).

• To exaggerate between oral position for /m/ and vowels in simple CV syllables: "Exaggerate the contrast between lips tightly closed and widely parted on /mah/, /maw/, and /mo/. Sustain the closed portion for a couple of seconds before opening the mouth" (Hanson, 1983, p. 201).

• To exaggerate overall precision of articulation: "When a [dysarthric] patient's articulatory movements are imprecise, he or she may be taught to exaggerate them, making them more precise" (Brookshire, 1992, p. 264-265).

 

10. Increase or Decrease Muscle Tone for Oral Movements

 

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

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

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• To decrease muscle tone in the tongue for production of lingua phonemes: "Request the patient to protrude the tongue so that it can be grasped gently. Next, pull it forward as completely as possible ... Once fully withdrawn the tongue is slowly pulled to the right corner of the mouth, held there for an out-loud count of 10 seconds, and then smoothly moved across the midline to the left corner of another count of 10 seconds to complete the trial. Although the degree of hypertonicity present will probably produce resistance to these adjustments, maintaining the lateral pulling force along the way usually proves fruitful after 10 or 15 trials with most patients" (Dworkin, 1991, p. 197).

• To increase muscle tone in the tongue: "Suction tongue against 'roof' of mouth, as if ready to 'pop.' Keep whole tongue tight against top and pull chin down ... Never [move the] tongue off the top. Repeat 5 times. This exercise can be difficult. If tongue falls [from] the top of the mouth, try again" (Czesak-Duffy, 1993, p. 28).

• To decrease muscle tone in the facial muscles: "Use facial molding ... begin with a general massage of the child's body and face ... gently mold or massage the face toward a closed mouth/closed lip position" (Morris & Klein, 2000, p. 415).

 

11. Increase Range of Motion for Oral Movements

 

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

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

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• To increase range of jaw, lip and tongue movements for speech: "Have the patient perform lip, tongue, lower jaw ... exercises calculated to give these organs increased flexibility and hence greater capacity to adjust themselves in new positions" (Borden & Busse, 1929, p. 182).

• To increase range of face, lip and jaw movements in speech warm-up activities: "Imitate the faces of clowns by retracting the lips, protruding the lips, and by dropping the jaw as far down as possible while producing [vowels]" (Berry & Eisenson, 1956, p. 139).

• To increase range of motion in the tongue for eating and swallowing: "The patient should be asked to open his or her mouth as wide as possible, hold it there for 1 second, and release it. Then the patient should elevate the back of the tongue as far as possible, hold it there for 1 second, and release it. This procedure should continue with the patient stretching the tongue to each side as far as possible, extending the tongue out of his or her mouth as far as possible, and pulling it back as far as possible, holding it for 1 second in each direction" (Logemann, 1983, p. 133).

 

12. Inhibit Oral Movements

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

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• To inhibit lip rounding for /l/: Place a small piece of Scotch tape. Vertically, at the corners of the mouth, with the lips slightly retracted. When the lips begin to move toward the /w/ position, the pulling of the tape signals the speaker that the unwanted movement is occurring" (Hanson, 1983, p. 214).

• To inhibit tongue humping or bunching in order to encourage more tongue movement: "Treatment approaches ... often include downward bouncing or patting on the tongue ... The tongue can be stroked to obtain a central grooving or a lateral upward movement ... Brushing the center of the tongue can facilitate flattening and a more central groove" (Morris & Klein, 2000, p. 607).

• To inhibit tip elevation during production of /k/: "Using a tongue depressor, hold the tongue tip down behind the lower teeth to hinder the elevation of the tongue tip" (Secord et al, 2007, p. 30).

 

13. Maintain Oral Positions

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

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• To maintain lip-to-lip articulation for swallowing: "Once the patient is able to obtain lip closure, but has not habituated it, a graduated increase in the time required to maintain closure should be used. The patient may be asked to hold lip closure for 1 minute. This should be repeated 10 times per day" (Logemann, 1983, pp. 145-146).

• To encourage lip-to-lip articulation for /p/: "Have the child pull the upper lip (using the lip muscles, not the finger) down over the upper teeth, with the mouth open, and hold for ten seconds" (Hanson, 1983, p. 201).

• To maintain positions for consonants and vowels: "Another speech-motor training program is the Monitoring Articulatory Postures (MAP) ... The program is in 3 phases. Phase I, Articulatory Posture Training, intends to teach the child to establish and to maintain vowel and consonant associated postures" (Jaffe, 1984, p. 178).

• To maintain tongue tip elevation to the alveolar ridge: "Hold tip of tongue to the spot for at least 5 seconds, or as long as possible. Increase time to 30 seconds, continuing to press tip into the spot" (Gangale, 1993, p. 103).

 

14. Mark the Target of Oral Movements

 

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

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• To mark the lateral portions of the palate for production of /s/: Use "two knotted dental floss guides placed between maxillary lateral incisors and cuspids" (Vaughn & Clark, 1979, p. 183).

• To mark the "spot" for tip-to-alveolar contact for correct oral rest posture: "At times we press against the spot with the end of a tongue depressor, then ask the patient to do the same. The parent watches closely, and may be asked to touch the child's 'spot' with a tongue depressor" (Hanson & Barrett, 1988, p. 275).

• To mark the soft palate for production of /k/: "Rub a moist cotton swab on a flavored food, such as a Lifesaver ... Then touch the soft palate near the second molars with the swab and ask the client to raise the back of the tongue to the roof of the mouth to form a seal" (Secord et al, 2007, pp. 30-31).

 

15. Model Oral Movements

 

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

• To model oral positions with apraxic patients: "Ordinarily, therapy is best conducted with the clinician and patient seated in front of a large mirror so the patient can watch both the clinician's face as he speaks and his own face as he imitates the clinician's model" (Darley, Aronson & Brown, 1975, p. 282).

• To model lip position for /m/: "Exaggerate the degree of inter labial contact and have the child imitate you" (Hanson, 1983, p. 200).

• To model tongue tip to the alveolar ridge for /t/: "Use hand gestures to demonstrate how to tap the tongue against the alveolar ridge" (Secord et al, 2007, p. 23).

 

16. Normalize Oral Tactile Sensitivity for Oral Movements

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

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• To normalize the hyper functional gag reflex that interferes with articulatory movement: "To lessen such sensitivity in these patients ... the technique of maintained touch or pressure may be helpful" (Dworkin, 1991, p. 104).

• To normalize sensitivity of the palate for lingua-alveolar, lingua-palatal and lingua-velar articulation: "We need to introduce touch to the front half of the palate, gradually moving back along the sides where the palate borders with the upper teeth. In the extremely sensitive mouth ... the clinician will find it helpful to return to working on the cheeks and activating the tongue so that the individual will alter his or her own sensitivity level with spontaneous movement. We can gradually reach a tolerance for sustained touch on the forward half of the palate" (Nelson & Benabib, 1991, pp. 156-157).

• To normalize oral tactile hypersensitivity for overall oral movement in speech and feeding: "If the child demonstrates atypical oral motor patterns, such as a hyper responsive gag reflex or tonic bite reaction, massage can be used to bring about an improved response" (Bahr, 2001, p. 115).

 

17. Practice Oral Movements

 

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

• To practice tongue tip elevation for /l/: "Give tongue-lifting and tongue-lowering exercises, first in silence, then while blowing, then while whispering ah, then while saying ah. Gradually lift the tongue [tip] higher and higher until it finally makes contact at the right place" (Van Riper, 1954, p. 242).

• To practice tongue tip elevation for lingua-alveolar phonemes: "Set the metronome to 30 [beats per minute], and instruct [the client] that the task is to raise and lower the tongue-tip alternately to the respective alveolar ridges according to the beat" (Dworkin, 1991, p. 223).

• To practice lip movements: "Pucker the lips, then relax; repeat ... Spread the lips, then relax; repeat ... Round the lips in a wide O, relax; repeat" (Bauman-Waengler, 2004, p. 225).

• For parents to practice lip movements with their children: "Blow bubbles ... Blow kisses ... Blow whistles or party favors ... Blow on a pinwheel ... Hum your favorite song together" (Dougherty, 2005, p. 89).

 

18. Resist Oral Movements

 

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

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• Use of resistance to facilitate lip protrusion: "[Have the client] retract the lips for e [i]; as the therapist holds them back, [the client should] force the lips into protrusion" (Berry & Eisenson, 1956, p. 139).

• Use of resistance to increase masseter strength: "The patient is asked to bite the posterior teeth together while counting to ten and forcing the masseter muscle to activate ... the forced activation of the masseter muscle strengthens it as the muscle adapts to the stress of biting action" (Garliner, 1981, p. 37).

• Use of resistance to facilitate lateral tongue elevation for /s/: "If the elevation is difficult, have him work on lifting the sides of the tongue against resistance. This resistance can be supplied by a pair of swab sticks pushing downward on the sides of the tongue" (Hanson, 1983, p, 228).

• Use of resistance to improve lip function using a quarter-sized button: "Loop the string through two buttonholes and tie a knot at the end. After instructing the patient to close the teeth, position the button against the teeth behind the midline of the lips ... In a tug-of-war fashion, pull on the string with moderate force as the patient is required to resist this effort to dislodge the button by vigorously contracting the circumoral musculature" (Dworkin, 1991, p. 213).

• Use of resistance to strengthen tongue-tip extension: "Stick out the tongue as far as possible, keeping it hard and straight. ... place horizontal length of [tooth] brush against tip. Push against tongue, keeping the tongue hard and unmoving" (Czesak-Duffy, 1993, p. 46).

 

19. Speed Up or Slow Down Oral Movements

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

• To increase speed of oral movement: "Chew in an exaggerated fashion ... Do this to a simple rhythm tapped out by the teacher, very slowly at first, then increasing speed" (Van Riper, 1954, p. 217).

• Adjusting speed of oral movement in the treatment of apraxia: "Slowing the rate gives the individual more time to process sensory information ... The speaker has more time to 'feel' the movement ... Varying the rate can be an effective tool during repetitive practice of targeted utterances. This will facilitate habituation of articulatory movement" (Yorkson, Beukelman, Strand & Bell, 1999, p. 552).

• To improve rate and rhythm of chewing: "Increase the timing and coordination of the chewing pattern ... Encourage rhythmic activities during chewing ... Many children will stomp their feet spontaneously or kick rhythmically as they are chewing" (Morris & Klein, 2000, p. 481).

 

20. Stabilize Oral Movements

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

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

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• To stabilize the jaw for improved tongue mobility for production of lingua phonemes: "Using a bite block to stabilize the mandible and reduce mandibular support during speech may help to increase independent lingual movement and result in improved oral articulation for speech ... [The] bite block is placed between the first molars on one or both sides ... With the block in place and following a period in which the child adjusts to the presence of the block, a series of speech sounds and sound sequences are presented for imitation by the child" (Crary, 1993, p. 224).

• To stabilize the lips and facial muscles with low muscle tone: "Play patty-cake, peek-a-boo, and other children's games that incorporate patting, tapping, stroking, and other types of tactile and proprioceptive stimulation of the cheeks and lips. Tapping can be done directly around the temporomandibular joint to provide better jaw stability for lip and cheek mobility" (Morris & Klein, 2000, p. 445).

• To stabilize the back of the tongue for eliminating a frontal lisp: "We can help our clients keep the tongue inside the mouth by developing [the tongue's] back lateral stability" (Marshalla, 2007, p. 115). Techniques include: "draw a picture," "stroke the zones," "smile," "bite gently on the zones," "establish the butterfly position," "hold the butterfly position," and "spread the back of the tongue" (p. 115-116).

 

21. Stimulate Reflexive Oral Movements

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

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• To stimulate tongue cupping: "The purpose of this exercise is to stimulate the involuntary reflex, similar to the grasp reflex, that depresses the middle portion of the tongue in response to a stimulus. ... Tap the middle of the tongue with a tongue depressor ... Continue tapping long enough to demonstrate the proper procedure, then have the patient do so. This is to be continued during each of the three practices each day for one minute" (Hanson & Barrett, 1988, pp. 278-279).

• To stimulate elevation of the tongue's lateral margins: "Touching or stroking a baby's tongue elicits a spoon-shaped lingual configuration, characterized by an upraised ridge around its outer border ... a similar posture could be elicited in adulthood by repeatedly touching, lightly stroking, or directing a stream of air across the tongue" (Fletcher, 1992, pp. 10-11).

• To stimulate elevation of the back of the tongue for lingua-velar phonemes: "Back elevation can be facilitated by stimulating the Tongue Retraction Response (TRR). ... Stroke down the middle of the tongue to about half way toward the back ... The whole tongue humps up and back into a ball shape which completely fills the posterior oral cavity and occludes the airway" (Marshalla, 1992, p. 98).

 

22. Vivify Gross Oral Movements

 

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

• To vivify general oral movement: "If these [phonetic placement] devices and instruments have any real value, it seems to be that of vivifying the movements of the tongue, and of providing a large number of varying tongue positions, from which the correct one may finally emerge" (Van Riper, 1954, p. 238).

• To facilitate gross movement of the tongue: "Chew gum, rolling it to the side, 'plaster' it against the palate, slowly move the gum back over the palate, etc. Attempt to feel the tongue position with each movement" (Berry & Eisenson, 1956, p. 139).

• To vivify gross oral movement for speech rehabilitation: "In instances of severe involvement ... movement may be so limited that differentiation of the various vowels and consonants is next to impossible. One can try in such a case to help the patient concentrate his energy first on activities preliminary to speech production ... The intent is to help the patient regain some concept of where his articulators are and where he must put them" (Darley, Aronson & Brown, 1975, p. 273-274).