7/7/2011 Peer Review Process Updating Evidence Against NSOME for - - PDF document

7/7/2011 1

Updating Evidence Against NSOME for Speech Sound Production

Presenter: Gregory Lof, Ph.D., CCC-SLP

Moderated by: Amy Hansen, M.A., CCC-SLP, Managing Editor, SpeechPathology.com

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7/7/2011 2 Updating Evidence Against Updating Evidence Against Nonspeech Oral Motor Exercises Nonspeech Oral Motor Exercises (NSOME) for Speech Sound (NSOME) for Speech Sound Productions Productions

Gregory L. Lof, PhD, CCC-SLP

Department Chair/Professor

July, 2011

Boston, MA

A special thanks to…

Dr Maggie Watson

• Dr. Maggie Watson

University of Wisconsin- Stevens Point

Why not Nonspeech Oral Motor Exercises (NSOME) to change (NSOME) to change speech sound productions?

• Do SLPs routinely use oral motor

exercises?

• Why do SLPs use them?

Are SLPs using Evidence Based Practice?

Some Practical Questions About Oral Motor Exercises

• What exercises do SLPs use?
• What proof do SLPs have that they

are effective in bringing about changes in speech-sound productions?

Practice

Outline of Talk

Trends

(using survey data)

Logical Reasons Not to Use Outline of Talk Not to Use Oral Motor Exercises

7/7/2011 3

Theoretical Reasons Not to Use Outline of Talk Not to Use Oral Motor Exercises Evidence Why Not to Use Outline of Talk Not to Use Oral Motor Exercises

Nonspeech Oral

Definitions

p Motor Exercises

Any technique that does not require the child to produce

Nonspeech Oral Motor Exercises Defined

q p a speech sound but is used to influence the development

• f speaking abilities.

Lof & Watson (2008)

A collection of nonspeech methods and procedures that are purported to influence tongue lip and jaw Nonspeech Oral Motor Exercises Defined to influence tongue, lip, and jaw resting postures, increase strength, improve muscle tone, facilitate range of motion, and develop muscle control.

(Ruscello, 2008)

Oral-motor exercises (OMEs) are nonspeech activities that involve sensory stimulation to or actions of the lips, jaw, tongue, soft palate, larynx, and respiratory muscles which are intended to

Nonspeech Oral Motor Exercises Defined

and respiratory muscles which are intended to influence the physiologic underpinnings of the

• ropharyngeal mechanism and thus improve its
• functions. They include active muscle exercise,

muscle stretching, passive exercise, and sensory stimulation.

McCauley, Strand, Lof, et al. (2009)

7/7/2011 4

Note that I will be talking about procedures and techniques that

Nonspeech Oral Motor Exercises Defined

do not use speech.

NSOME NSOME

Not about: Not about:

feeding, swallowing, drooling feeding, swallowing, drooling

Nonspeech Oral Motor Exercises Defined

g g g g g g

S p e e c h

Do SLPs Use NSOME?

Nationwide Survey Do SLPs Use NSOME?

Lof & Watson (2008)

Nationwide survey of 537 SLPs

85% use NSOME to

Do SLPs Use NSOME?

85% use NSOME to change speech sound productions

Lof & Watson (2008)

Nationwide survey of 535 SLPs in Canada

Do SLPs Use NSOME?

Hodge, Salonka, & Kollias, (2005)

7/7/2011 5

Nationwide survey of 535 SLPs in Canada

85% use NSOME to

Do SLPs Use NSOME?

85% use NSOME to change speech sound productions!

Hodge, Salonka, & Kollias, (2005)

Survey of SLPs in Kentucky

Do SLPs Use NSOME?

Approximately 79% use

Cima, Mahanna-Boden, Brown, & Cranfill (ASHA, 2009)

79% use NSOME to change speech sound productions

Survey of SLPs in South Carolina

Do SLPs Use NSOME?

Approximately 81% believe

Lemmon, Harrison, Woods-McKnight, Bonnette, & Jackson, (ASHA, 2010)

NSOME are at least somewhat effective in bringing about speech sound improvements

Do SLPs Use NSOME?

How did clinicians learn How did clinicians learn about NSOME? about NSOME?

Lof & Watson (2008)

87% from CE

• fferings,

workshops, In-services

87%

Do SLPs Use NSOME?

How did clinicians learn How did clinicians learn about NSOME? about NSOME?

25% f i it

Watson & Lof (2009)

25% of university professors who teach speech sound disorders teach NSOME

75%

Rank order of most frequently used exercises: Rank order of most frequently used exercises:

• 1. Blowing
• 6. Tongue-to-nose-to chin

Do SLPs Use NSOME?

• 2. Tongue push-ups
• 3. Pucker-smile
• 4. Tongue wags
• 5. Big smile
• 7. Cheek puffing
• 8. Blowing kisses
• 9. Tongue curling

Lof & Watson (2008)

7/7/2011 6

Rank order of most frequently identified Rank order of most frequently identified “benefits” of these exercises: “benefits” of these exercises:

Do SLPs Use NSOME?

• 1. Tongue elevation
• 2. Awareness of articulators
• 3. Tongue strength
• 4. Lip strength
• 5. Lateral tongue movements
• 6. Jaw stabilization
• 7. Lip/tongue protrusion
• 8. Drooling control
• 9. VP competence

10.Sucking ability

Lof & Watson (2008)

Clinicians Clinicians USUALLY USUALLY use these use these exercises for children with… exercises for children with…

Do SLPs Use NSOME?

• 1. Dysarthria
• 2. Childhood Apraxia of Speech (CAS)
• 3. Structural anomalies (e.g., clefts)
• 4. Down syndrome

Lof & Watson (2008)

Do SLPs Use NSOME?

Clinicians Clinicians FREQUENTLY FREQUENTLY use these use these exercises for children with… exercises for children with…

• 1. In early intervention
• 2. Late talkers
• 3. Phonologically impaired
• 4. Hearing impaired
• 5. Functional misarticulators

Lof & Watson (2008)

Evidence-Based Practice

• The conscientious, explicit, and unbiased

use of current best research results in making decisions about the care of i di id l li t

Evidence-Based Practice

individual clients.

• Treatment decisions should be

administered in practice only when there is a justified (evidence-based) expectation of benefit.

Sackett et al., (1996)

Research Evidence

Evidence-Based Practice

EBP

Clinical Experience Client Values

7/7/2011 7

EBP is the integration of best research evidence along with clinical expertise and the client values

Evidence-Based Practice

and the client values

EBP uses the best evidence available, in consultation with the client or parents to decide upon the options that suits the client best.

The Purpose of EBP

P t

Evidence-Based Practice

Promote

the adoption of effective interventions

The Purpose of EBP

Evidence-Based Practice

Delay

the adoption of unproved interventions

The Purpose of EBP

Evidence-Based Practice

Prevent

the adoption of ineffective interventions

Evidence-Based Practice

Most of the evidence th ffi f

Levels of Evidence from Studies

• n the efficacy of

NSOME is on the somewhat weaker side, but…

Evidence-Based Practice

Levels of Evidence from Studies

LEVEL Ib:

STRONG Well designed randomized controlled study

LEVEL Ia: STRONGEST Well-designed meta-analysis of >1 RCT LEVEL Ib: STRONG

Well-designed randomized controlled study

LEVEL IIa: MODERATE Well-designed controlled study without randomization LEVEL IIb: MODERATE Well-designed quasi-experimental study LEVEL IV: WEAK

Opinion of authorities, based on clinical experience

LEVEL III: LIMITED

Nonexperimental studies (i.e., correlational and case studies)

7/7/2011 8

Dollaghan (2004, 2007) reminds clinicians that when using the EBP paradigm, valid and reliable evidence needs to be given more credence than intuition anecdote and

Evidence-Based Practice

more credence than intuition, anecdote and expert authority. While opinions and clinician's own clinical experiences can be useful, they can also be biased and even wrong!

Finn, Bothe, & Bramlett (2005)

Evidence-Based Practice

Science and Pseudoscience in Communication Disorders: Criteria and Applications

Science

Evidence-Based Practice

vs. Pseudoscience

Finn, Bothe, & Bramlett (2005)

Science: Science:

Evidence-Based Practice

Information is developed through research and

• ther empirically based

activities.

Finn, Bothe, & Bramlett (2005)

Pseudoscience: Pseudoscience:

“A pretend or spurious science; a

Evidence-Based Practice

p p ; collection of related beliefs about the world mistakenly regarded as being based on scientific method or as having the status that scientific truths now have.”

Finn, Bothe, & Bramlett (2005)

Quackery and Pseudoscience can go together

Quackery is anything

Evidence-Based Practice

Quackery is anything involving over-promotion in a clinical field

Finn, Bothe, & Bramlett (2005)

Includes questionable ideas and questionable products and services, regardless of the sincerity of the promoters

7/7/2011 9

You know it is

Evidence-Based Practice

it is Pseudoscience when…

Finn, Bothe, & Bramlett (2005)

Disconfirming evidence is ignored and practice

You know it is …

You know it is pseudoscience when…

is ignored and practice continues even though the evidence is clear.

Finn, Bothe, & Bramlett (2005)

The only “evidence” is anecdotal, supported with

You know it is …

You know it is pseudoscience when… supported with statements from personal experience (testimonials)

Finn, Bothe, & Bramlett (2005)

Inadequate

You know it is …

You know it is pseudoscience when…

evidence is accepted

Finn, Bothe, & Bramlett (2005)

The printed materials

You know it is …

You know it is pseudoscience when…

are not peer reviewed

Finn, Bothe, & Bramlett (2005)

Grandiose outcomes are proclaimed

You know it is …

You know it is pseudoscience when…

Finn, Bothe, & Bramlett (2005)

7/7/2011 10

Muttiah, Georges, & Brackenbury (2011)

Evidence-Based Practice

Qualitative Study: Interviews with

• 11 clinicians who use

NSOME

• 11 researchers who

are against their use

Oral Motor Tasks…

This is the logical part

Tongue Push-Ups Objective: to strengthen tongue Procedure: child holds up an M&M, cheerio, etc. on upper ridge just behind teeth (not on teeth) and pushes up with tongue.

Some Exercises From the Web:

http://www.widesmiles.org/cleftlinks/WS-563.html

Tongue Pops Objective: To strengthen tongue Procedure: Suck tongue up on the top of the mouth, pull it back and release it, making a popping sound. Pointy Tongue Objective: To increase tongue movement and coordination Procedure: Protrude tongue and point it at the tip. Whistle Objective: To increase lip strength Procedure: Have child pucker lips and blow attempting to whistle. Fish Mouth

Some Exercises From the Web:

http://www.widesmiles.org/cleftlinks/WS-563.html

Objective: To increase oral-motor strength Procedure: Pucker lips and suck cheeks in to make a "fish-face" Pucker-Smile Objective: To increase oral-motor coordination Procedure: Have child close mouth with back teeth together. Have child pucker lips (while keeping back teeth together). Once mastered, have child alternate a pucker with a smile.

Some questions to ask yourself as you

Do NSOME make logical sense?

yourself as you evaluate these tasks…

7/7/2011 11

Do NSOME make logical sense?

There is evidence that shows that NSOME do shows that NSOME do not work. Why is it being ignored?

Do NSOME make logical sense?

There is NO evidence that shows that that shows that NSOME do work. Why is this being ignored?

Do NSOME make logical sense?

Why are the materials and procedures used in and procedures used in NSOME not brought up for peer-review scrutiny?

Do NSOME make logical sense?

Why are the materials and procedures and procedures promoted only in self-published materials and on websites?

Do NSOME make logical sense?

Why do these websites h ti f have a section for “testimonials” but not for “research”?

Do NSOME make logical sense?

How could one procedure work to procedure work to remediate so many disparate types of problems?

7/7/2011 12

Do NSOME make logical sense?

For example, look at some of the catalogs that promote NSOME…

From a Catalog:

Grandiose outcomes are proclaimed

If i i d

Remember Pseudoscience

If it is too good to be true, it probably is not true!

Finn, Bothe, & Bramlett (2005)

Do NSOME make logical sense?

What is the monetary benefits to the promoters of NSOME?

Are NSOME Logical?

?

7/7/2011 13

Now For the Theory Part

Part-whole training and transfer Strengthening the structures

Why Exercises are THOUGHT to be Effective

Strengthening the structures Relevancy to the act of speaking Task specificity Warm-up/Awareness/Metamouth

Part-Whole Training and Transfer Part-Whole Training and Transfer

Premise:

If we teach smaller parts of a If we teach smaller parts of a speech gesture, it will help in the acquisition of the whole speech gesture.

Part-Whole Training and Transfer

However, it has been shown that…

Tasks that comprise highly organized or g y g integrated parts will not be enhanced by learning of the constituent parts; rather, training on parts of these organized behaviors may diminish learning.

Part-Whole Training and Transfer

What this means...

Highly organized tasks require l i f th i f ti learning of the information processing demands as well as learning time sharing and other intercomponent skills.

7/7/2011 14

Part-Whole Training and Transfer

“Fractionating a behavior that is composed of interrelated parts i t lik l t id l t is not likely to provide relevant information for the appropriate development of neural substrates.”

Forrest (2002)

Part-Whole Training and Transfer

It is the breaking the whole task i t ll into small, meaningless subtasks that will not be effective.

Part-Whole Training and Transfer

An example of this was recently reported to me by a student clinician who was assigned to a practicum with a school SLP. The student described how they had been extensively drilling a child to use a “lower had been extensively drilling a child to use a lower lip biting” maneuver with the ultimate goal of evoking the /f/ sound. During the many sessions with the child, they never worked on the actual speech sound, instead only practiced the isolated exaggerated lingual-dental gesture.

Part-Whole Training and Transfer

“Training the Whole”

Ingram & Ingram (2001)

“Whole-Word Phonology and Templates”

Velleman & Vihman (2002)

Part-Whole Training and Transfer

Summary

–Learning of tasks with interdependent parts is not improved by decomposition. –Fractionation and simplification of a task do not yield any improvements in learning a target behavior. –Do not break things into small subtasks because there probably will be no transfer

• f that skill to the whole.

Part-whole training and transfer Strengthening the structures

Why Exercises are THOUGHT to be Effective

Strengthening the structures Relevancy to the act of speaking Task specificity Warm-up/Awareness/Metamouth

7/7/2011 15

Increase in Strength Do SLPs USE NSOME?

Rank order of most frequently identified “benefits” of these exercises:

• 1. Tongue elevation
• 2. Awareness of articulators
• 3. Tongue strength
• 4. Lip strength
• 5. Lateral tongue movements
• 6. Jaw stabilization
• 7. Lip/tongue protrusion
• 8. Drooling control
• 9. VP competence

10.Sucking ability

Lof & Watson (2008)

Four Questions about Strength:

• 1. Is strength needed for speech?

Increase in Strength

• 2. Will NSOME actually increase strength?
• 3. How is strength adequately measured?
• 4. Do children with speech sound disorders

have weakness?

Question Question 1 1

Is strength needed

Increase in Strength

Is strength needed for speech?

Strength needs for speech are VERY low

– Lip muscle force for speaking is only about 10- 20% of the maximal capabilities of lip force.

Increase in Strength

p p – The jaw uses only about 11- 15% of available amount of force that can be produced. – Activation of the laryngeal muscles is between 10% - 20% of maximum.

Strength needs for speech are VERY low

In other words, the speaking strength d d t h l t

Increase in Strength

needs do not come anywhere close to the maximum strength abilities of the articulators.

7/7/2011 16

Strength needs for speech are VERY low

“…only a fraction of maximum tongue force is used in speech production, and such

Increase in Strength

used in speech production, and such strength tasks are not representative of the tongue's role during typical speaking. As a result, caution should be taken when directly associating tongue strength to speech…”

Wenke, Goozee, Murdoch, & LaPointe (2006)

Strength needs for speech are VERY low

Children need agility and fine ti l t t

Increase in Strength

articulatory movements

Strength needs for speech are VERY low

Children need agility and fine articulatory movements

–Need agility, not strength

Increase in Strength

Need agility, not strength –NSOME encourages gross and exaggerated ranges of motion, not small, coordinated movements that are required for talking

Strength needs for speech are VERY low

Children need agility and fine articulatory movements

– Motor SKILL training induces motor map

Increase in Strength

g p reorganization, whereas strength training does not (Remple et al., 2001). – Exercise alone (as opposed to skill training) will not alter motor map organization (Kleim et al., 2002).

Strength needs for speech are VERY low

Children need agility and fine articulatory movements

– Different adaptive changes are evoked with

Increase in Strength

p g strength training than with skill training (Jensen et al., 2005).

Question Question 2 2

Will NSOME

Increase in Strength

Will NSOME actually strengthen the articulators?

7/7/2011 17

A non-speaking example:

Bicep weight training

Increase in Strength

• Repetitions to failure?
• Repetitions to failure?
• Against resistance?
• Increase agility and

range of motion?

A non-speaking example:

Bicep weight training

Increase in Strength

Do people who use NSOME follow this basic strength training paradigm?

Will NSOME actually strengthen the articulators? Bl i i id i

Increase in Strength

A Speaking Example: VP Closure

Blowing exercises can aid in velopharyngeal closure for

• ther blowing tasks; but this

closure is not maintained for speaking. Will NSOME actually strengthen the articulators? Li l i i

Increase in Strength

A Tongue Exercise Example with Normal Adults

Lingual exercises using protrusion and lateralization, 30 repetitions a day, 7 days a week, for 9 weeks

Clark, O’Brien, Calleja, & Corrie (2009)

Will NSOME actually strengthen the articulators? P d d 6% t 26%

Increase in Strength

A Tongue Exercise Example with Normal Adults

Produced 6% to 26% increase in strength. Significant loss of strength (back to baseline) once training ended.

Clark, O’Brien, Calleja, & Corrie (2009)

Will NSOME actually strengthen the articulators?

Increase in Strength

A Swallowing Example

Lingual exercises can strengthen the tongue and it can have an effect

• n swallowing.

Robbins, J., Gangnon, R., Theis, S., Kays, S., Hewitt, A., & Hind, J. (2005)

7/7/2011 18

But it takes A LOT of exercises:

• 8 weeks
• 30 exercises against resistance

A Swallowing Example

Increase in Strength

• 3 times a day
• Every other day

Strength increased: only ~ 6 kPa or ~ 17% increase in 8 weeks

Increase in Strength

Lip Strengthening Exercises

• 8 7-19 year olds with Myotonic Dystrophy Type 1
• Counter balanced design for 32 weeks
• Exercised 16 minutes 5 days/week against resistance

Sjögreena, L., Tuliniusb, M., Kiliaridisc, S., & Lohmanderd, A. (2010). The effect of lip strengthening exercises in children and adolescents with myotonic dystrophy type 1. International Journal of Pediatric Otorhinolaryngology, 74(10), 1126-1134.

• Exercised 16 minutes, 5 days/week against resistance
• Results:
• Only 4 improved maximal lip strength
• Lip strength did not lead to improved function for

speech, eating, drinking, mobility, or saliva control

• Strength was not maintained over time

Increase in Strength

Will NSOME actually strengthen the articulators?

Only if the standard strength training paradigm is followed training paradigm is followed.

But it may not improve function!

Question Question 3 3

How is strength

Increase in Strength

How is strength adequately measured?

Measurements of

Increase in Strength

strength are usually highly subjective

Measurement of strength is typically done subjectively

Increase in Strength

For example, feeling the force of the tongue pushing against a tongue depressor or against the cheek

7/7/2011 19 Measurement of strength is typically done subjectively

T t t th li i i l h ld

Increase in Strength

To assess tongue strength, clinicians commonly hold a tongue depressor beyond the lips and the patient pushes the tongue against the depressor. Strength is rated perceptually,

• ften with a 3-5 point equal-appearing interval scale or with

binary judgments of “normal” or “weak.”

Solomon & Monson (2004)

Measurement of strength is typically done subjectively

Increase in Strength

Objective measures of strength have been recommended as more valid and reliable than subjective measures for the assessment of tongue function, yet subjective measures remain the more commonly used clinical method.

Clark, Henson, Barber, Stierwalt & Sherrill (2003)

Measurement of strength is typically done subjectively

Increase in Strength

Because of this, clinicians cannot initially verify that strength is diminished and they cannot report increased strength following NSOME

Only objective measures can corroborate statements of strength needs and strength improvement.

Increase in Strength

p

(e.g., dynamometer, force transducer, IOPI)

Without such measurements, testimonials

• f strength gains are suspect.

Tongue Force Transducer

Iowa Oral Performance Instrument (IOPI)

7/7/2011 20

When tongue strength assessments were done with a tongue depressor compared with the IOPI, it was found that there was only a weak correlation.

Increase in Strength

Student clinicians were actually better at estimating strength than were experienced clinicians (but nether were very good).

Clark, Henson, Barber, Stierwalt & Sherrill (2003)

How is strength adequately measured?

Increase in Strength

Usually with subjectivity so statements about weakness are questionable.

Question Question 4 4

Do children with speech

Increase in Strength

Do children with speech sound disorders have weak tongues?

Sudberry, Wilson, Broaddus, & Potter (2006)

• Used the Iowa Oral Pressure Instrument (IOPI)

Increase in Strength

• 30 typically developing preschool children and 15 with

speech sound disorders.

• Children with speech sound disorders had

STRONGER tongues than typically developing children!!!

Dworkin & Culatta (1980)

No difference in tongue strength comparing controls with children who “lisp” and children

Increase in Strength

controls with children who “lisp” and children with a tongue thrust.

Dworkin & Culatta (1980)

“The present findings suggest that tongue

Increase in Strength

The present findings suggest that tongue strengthening exercises may be superfluous to the correction of tongue thrusting or associate frontal lisping.”

7/7/2011 21 Tone vs. Strength

• Muscle tone refers to the resilience or elasticity of

the muscle at rest.

Increase in Strength

• "Low tone" indicates less contraction of the

fibers than typical.

• Observing low tone does not automatically mean

that the child has weakness.

• Working on strengthening probably will not

influence tone.

Clark, 2010

Summary

• Strength needs for speaking are very low.
• We need agile movements not strong

Increase in Strength

We need agile movements, not strong movements.

• NSOME probably are not adding strength.
• Subjective measures of strength are not valid.
• Children with speech sound disorders probably

don’t have weak tongues.

Part-whole training and transfer Strengthening the structures

Why Exercises are THOUGHT to be Effective

Strengthening the structures Relevancy to the act of speaking Task specificity Warm-up/Awareness/Metamouth

Relevancy of NSOME to Speech

NSOME

Relevancy of NSOME to Speech

lack RELEVANCY

RELEVANCY is the issue

Relevancy is the way to get changes in the neural system

Relevancy of NSOME to Speech

Context is Crucial

7/7/2011 22

RELEVANCY is the issue

Relevancy is the way to get changes in the neural system

Relevancy of NSOME to Speech

Context is Crucial In order to obtain transfer from one skill to another, the learned skill must be relevant to the other skills. For sensory motor stimulation to improve articulation, the stimulation must be done with relevant behaviors with a defined end goal, using integration of skills.

RELEVANCY is the issue

Relevancy is the way to get changes in the neural system

Relevancy of NSOME to Speech

Context is Crucial

“The purpose of a motor behavior has a profound influence

• n the manner in which the relevant neural topography is

marshaled and controlled.”

Weismer (2006)

A non-speaking example:

Sh ti b k tb ll

Relevancy of NSOME to Speech

Shooting a basketball

Why DIS-INTEGRATE?

Another non-speaking example:

Relevancy of NSOME to Speech

Dribbling a Basketball

Another non-speaking example:

Relevancy of NSOME to Speech

Playing the Piano One final non-speaking example:

Why shoot a basketball

Relevancy of NSOME to Speech

Why shoot a basketball without an actual hoop?

The end goal needs to be practiced!

7/7/2011 23 One final non-speaking example:

Breaking down basketball

Relevancy of NSOME to Speech

g shooting or the speaking task into smaller, unrelated chunks that are irrelevant to the actual performances is not effective.

Talk about irrelevant…

For example practicing tongue

Relevancy of NSOME to Speech

For example, practicing tongue elevation to the alveolar ridge with the desire that this isolated task will improve production of /s/ is dis-integrating the highly integrated task of speaking.

Improving speaking ability must be practiced in the context of speaking.

Relevancy of NSOME to Speech

To improve speaking, children must practice speaking, rather than using tasks that only superficially appear to be like speaking.

Isolated movements of the tongue, lips and

• ther articulators are not the actual

gestures used for the production of sounds

Relevancy of NSOME to Speech

g p in English. Oral movements that are irrelevant to the speech movements will not be effective therapeutically.

No speech sound requires the tongue tip to be elevated toward the nose no

Relevancy of NSOME to Speech

to be elevated toward the nose, no sound is produced by puffing out the cheeks, no sound is produced in the same way as blowing is produced.

Relevancy of NSOME to Speech

7/7/2011 24 Summary

• Only movements relevant to speaking are

effective.

Relevancy of NSOME to Speech

• The end goal—speaking–must be practiced.
• Disintegrating highly integrated movements are

not effective.

• No speech sounds are produced with the

tongue in strange positions, cheeks puffed out, etc.

Part-whole training and transfer Strengthening the structures

Why Exercises are THOUGHT to be Effective

Strengthening the structures Relevancy to the act of speaking Task specificity Warm-up/Awareness/Metamouth

Task Specificity

Do the same structures used for other “mouth tasks”

Task Specificity

for other “mouth tasks” function the same as for speech?

Respondents who reported they believe speech develops from early oral motor

Do SLPs USE NSOME?

speech develops from early oral motor behaviors such as sucking and chewing:

Lof & Watson (2008)

60%

This means that clinicians believe that early experiences with sucking and chewing lead directly to speech.

Task Specificity

lead directly to speech. However, chewing and babbling have been shown to have no relation. Early mouth movements are not precursors to speech.

Moore & Ruark (1996)

7/7/2011 25

T k S ifi it

Task Specificity

Task Specificity T k S ifi it

Task Specificity

Task Specificity

Same Structures but Different Functions

• The same structures used for speaking and
• ther “mouth tasks” (e.g., feeding, sucking,

swallowing, breathing, etc.) function in different ways depending on the task

Task Specificity

ways depending on the task.

• Each task is mediated by different parts of the

brain.

• The organization of movements within the

nervous system is not the same for speech and nonspeech.

Although identical mouth structures are used these

Task Specificity

structures are used, these structures function differently for speech and for nonspeech activities. The control of motor behavior

Task Specificity

is task specific, not effector (muscle or organ) specific. There is strong evidence

Task Specificity

against the “shared control” for speech and nonspeech.

7/7/2011 26

Bonilha, Moser, Rorden, Baylis, & Bridriksson (2006). Speech apraxia ith t l i C l b i

Task Specificity

without oral apraxia: Can normal brain function explain the physiopathology? Neuro Report, 17 (10), 1027-1031.

Bonilha, Moser, Rorden, Baylis, & Bridriksson (2006)

Finding:

Non-speech motor movements

Task Specificity

p elicited activation of different parts of the brain than did speech motor movements.

Bonilha, Moser, Rorden, Baylis, & Bridriksson (2006)

Schulz, Dingwall, & Ludlow (1999). Speech and oral motor learning in

Task Specificity

Speech and oral motor learning in individuals with cerebral atrophy. Journal of Speech, Language and Hearing Research, 42, 1157-1175.

Schulz, Dingwall, & Ludlow (1999)

• Normal adults and adults with cerebral pathology

Task Specificity

• Practiced speech and nonspeech movements
• FINDINGS:

Schulz, Dingwall, & Ludlow (1999)

• Difference in the effect of learning between speech and

nonspeech movements for both groups.

• There is a difference in the degree of change in cortical

physiology in response to training for speech and

Task Specificity

physiology in response to training for speech and nonspeech tasks.

• It cannot be assumed that the type of pattern of cortical or

behavior adaptations are equivalent for speech and nonspeech tasks.

• Important to consider “speech motor control” that is

different from other motor control.

Schulz, Dingwall, & Ludlow (1999)

Task Specificity

Ludlow, C., Hoit, J., Kent, R., Ramig, L., Shrivastav, R., Strand, E., Yorkston, K., & Sapienza C (2008) Translating principles of Sapienza, C. (2008). Translating principles of neural plasticity into research on speech motor control recovery and rehabilitation. Journal of Speech, Language and Hearing Research, 51, S240-S258.

Ludlow et al. (2008)

7/7/2011 27

• Changes in neural function with practice are

limited to the specific function being trained.

• For example, training on lip strength will only

Task Specificity

benefit the neural control for lip movement and force with no spontaneous transfer to speech production.

• Changes occur only in the neural substrates

involved in the particular behavior being trained.

Ludlow et al. (2008)

Yee, Vick, Venkatesh, Campbell, Shriberg, Green, Rusiewicz, & Moore (Nov., 2007).

Task Specificity

Green, Rusiewicz, & Moore (Nov., 2007). Children’s mandibular movement patterns in two nonspeech tasks.

74 36-60 month olds:

42 with “speech delay” 32 typically developing

Task Specificity

32 typically developing

2 tasks:

• 1. Silent jaw oscillations (imitation of speech

movements in response to a model)

• 2. Mastication (chewing a single Goldfish

cracker)

Yee et al. (2007)

Analyzed the cyclic movements of the mandible across groups and tasks

FINDINGS

Task Specificity

FINDINGS

• Speech and nonspeech tasks exhibited distinct patterns
• Typically developing and children with speech disorders

did not differ

Yee et al. (2007)

7 Research Examples of Task Specificity

Babbling and Early Oral Behaviors

NOT related to each other

Moore & Ruark (1996)

7 Research Examples of Task Specificity

Speech and Swallowing

• Dysphagia with speech problems
• Dysphagia without speech problems
• Speech problems without dysphagia

Green & Wang (2003); Martin (1991); Ziegler (2003)

7/7/2011 28

S h d S ll i

7 Research Examples of Task Specificity

Speech and Swallowing

Can strengthen the oral structures for the oral phase of swallowing but it will have no impact on speaking

Robbins et al. (2005)

7 Research Examples of Task Specificity

Strengthening VP

Can strengthen the VP complex, but it does not reduce nasalized speech

(many studies since the 1960s)

7 Research Examples of Task Specificity

Breathing for Speech

Different than breathing at rest or during other activities

e.g., Moore, Caulfield, & Green (2001)

7 Research Examples of Task Specificity Tongue Thrust Therapy

Oral myofunctional therapy improves the tongue thrust, but not speech productions

Gommerman & Hodge (1995); Christensen & Hanson (1981)

7 Research Examples of Task Specificity

Diadochokinetic Syllable Repetition

Syllable repetition and speech production rate and accuracy are unrelated; training these movements will not improve speech.

McAuliffe, Ward, Murdoch, & Farrell (2005)

7 Research Examples of Task Specificity Silent Tongue Movements

Silent tongue movements produced symmetric brain activation in the right and left primary motor regions; phonation with tongue movements produced activation in the left hemisphere.

Terumitsu, Fujii, Suzuki, Kwee, & Nakada (2006)

7/7/2011 29

Summary of 11 Research Studies Summary of 11 Research Studies

Speech and Nonspeech are different for:

Other Research Examples of Task Specificity

• facial muscles
• jaw motion
• jaw operating space
• jaw coordination
• lingual movement
• lip motions
• levator veli palatini
• mandibular control

Weismer (2006)

Summary

• The same oral structures function differently for

speech and for nonspeech movements.

Task Specificity

p p

• Working on nonspeech activities will not

develop the necessary neural pathways for speaking.

• Speech is special and unlike other oral

movements.

Part-whole training and transfer Strengthening the structures

Why Exercises are THOUGHT to be Effective

Strengthening the structures Relevancy to the act of speaking Task specificity Warm-up/Awareness/Metamouth

Warm-Up, Awareness and Metamouth

Do SLPs USE NS-OME?

Rank order of most frequently identified “benefits” of these exercises:

1. Tongue elevation 2. Awareness of articulators 3. Tongue strength 4. Lip strength 5. Lateral tongue movements 6. Jaw stabilization 7. Lip/tongue protrusion 8. Drooling control 9. VP competence

• 10. Sucking ability

Lof & Watson (2008)

2 points about this…

1 Warm-up from a physiological

Warm-Up, Awareness and Metamouth

1.Warm up from a physiological point of view

• 2. “Meta-mouth” awareness

7/7/2011 30

Warm up from a physiological point of view

Awareness and “Warm-Up”

Purpose of warm- up muscle exercise:

To increase blood circulation so muscle viscosity drops, thus allowing for smoother and more elastic muscle contractions

Warm up from a physiological point of view

Awareness and “Warm-Up”

When is muscle warm-up appropriate?

When a person is about to initiate an exercise regimen that will maximally tax the system (e.g., distance running, weight lifting)

Warm up from a physiological point of view

Awareness and “Warm-Up”

When is muscle warm-up NOT appropriate? Muscle warm-up is not required for tasks that are below the maximum (e.g., walking, lifting a spoon-to-mouth) Warm up from a physiological point of view

Awareness and “Warm-Up”

When waking up in the morning it is doubtful that many people it is doubtful that many people warm-up their arms before dressing, or warm-up their mouths before uttering their first “good morning” because the muscles are already prepared for such tasks.

Metamouth

? Providing some form of knowledge

Metamouth

about the articulators’ movement and placement

7/7/2011 31 For articulation awareness, children age 5 and 6 years have very little

Metamouth

age 5 and 6 years have very little consciousness of how speech sounds are made; 7 year olds are not very proficient with this either.

Klein, Lederer & Cortese (1991)

Children can make use of metamouth knowledge perhaps

Metamouth

metamouth knowledge perhaps after age 7 if they have the “…cognitive maturity required to understand the concept of a sound.”

Koegel, Koegel, & Ingham (1986)

It appears that young children cannot take advantage of the non

Metamouth

cannot take advantage of the non- speech mouth-cues provided during NSOME that can be transferred to speaking tasks. Summary

• Muscles do not need to be warmed up if they

are not being taxed.

Warm-Up, Awareness and Metamouth

g

• NSOME do not “wake up” the mouth for

speaking.

• Children probably cannot make use of the

mouth cues provided during NSOME that will aid in articulatory movements for speech.

Disorders that SLPs Use NSOME

The L O N G list of list of disorders that clinicians use NSOME in therapy…

Disorders that SLPs Use NSOME

• Childhood Apraxia of Speech (CAS)
• Dysarthria
• Structural anomalies (e.g., clefts)

D d

• Down syndrome
• In early intervention
• Late talkers
• Phonologically impaired
• Hearing impaired
• Functional misarticulators

Lof & Watson (2008)

7/7/2011 32

NSOME and Childh d A i f S h

Disorders that SLPs Use NSOME

Childhood Apraxia of Speech

(CAS)

It is puzzling why clinicians would use NSOME, especially for children with CAS.

Disorders that SLPs Use NSOME—CAS

By definition, children with CAS have adequate oral structure movements for nonspeech activities but not for volitional speech (Caruso & Strand, 1999). There can be no muscle weakness of children with CAS, so there is no need to do strengthening exercises.

Disorders that SLPs Use NSOME—CAS

If there is weakness, then the correct diagnosis is dysarthria, not apraxia. “The focus of intervention for the child diagnosed with CAS is on improving the planning, sequencing, and coordination of

Disorders that SLPs Use NSOME—CAS

p g, q g, muscle movements for speech. Isolated exercises designed to "strengthen" the oral muscles will not help. CAS is a disorder of speech coordination, not strength.”

ASHA Position Paper and Technical Report (2007)

NSOME and

Disorders that SLPs Use NSOME

NSOME and Cleft Lip/Palate

The VP mechanism can be strengthened through exercise, but added strength will not improve speech production.

Disorders that SLPs Use NSOME—Cleft Lip/Palate

Blowing exercises are not an appropriate therapeutic technique.

Peterson-Falzone, Trost-Cardamone, Karnell, Hardin-Jones (2006)

7/7/2011 33 Disorders that SLPs Use NSOME—Cleft Lip/Palate See these references:

• Peterson-Falzone, Trost-Cardamone,

Karnell, Hardin-Jones (2006) , ( )

• Goldening-Kushner, K. (2001)
• Ruscello (2008)

“Do not invest time or advise a parent to invest time and money addressing a muscle strength problem that may not (and probably does not) exist. It is very frustrating to see clinicians working on “exercises” to

Disorders that SLPs Use NSOME—Cleft Lip/Palate

frustrating to see clinicians working on “exercises” to strengthen the lips and tongue tip when bilabial and lingua-alveolar sounds are already evident in babble,

• r when bilabial and lingual/lingua-alveolar functions

are completely intact for feeding and other nonspeech motor behaviors.”

Peterson-Falzone, Trost-Cardamone, Karnell, Hardin-Jones (2006)

“Having a repaired cleft does not mean a child will lack the muscle strength needed to produce consonant sounds adequately. The presence of a cleft palate (repaired or unrepaired) has no

Disorders that SLPs Use NSOME—Cleft Lip/Palate

p ( p p ) bearing on tongue strength or function (why would it?). The majority of children who demonstrate VPI do so because their palate is too short to achieve VP closure. Muscle strength or lack thereof is not a primary causal factor associated with phonological delays in this population.”

Peterson-Falzone, Trost-Cardamone, Karnell, Hardin-Jones (2006)

“…blowing should never be used to “strengthen” labial or soft palate musculature; it does not work. Children who appear to improve over time in

Disorders that SLPs Use NSOME—Cleft Lip/Palate

therapy when using these tools are likely demonstrating improvement related to maturation and to learning correct motor speech patterns. Had therapy focused only on speech sound development, these children probably would have shown progress much sooner.”

Peterson-Falzone, Trost-Cardamone, Karnell, Hardin-Jones (2006)

“Blowing exercises, sucking, swallowing, gagging, and cheek puffing have been suggested as useful in improving or strengthening velopharyngeal closure and speech. However, multiview videofluoroscopy

Disorders that SLPs Use NSOME—Cleft Lip/Palate

p py has shown that velopharyngeal movements of these nonspeech functions differ from velopharyngeal movements for speech in the same speaker. Improving velopharyngeal motion for these tasks do not result in improved resonance or speech. These procedures simply do not work and the premises and rationales behind them are scientifically unsound.”

Goldening-Kushne, 2001

NSOME for Non-Motor Speech Disorders

Disorders that SLPs Use NSOME

Non Motor Speech Disorders

(e.g., Late Talkers, Children in early intervention, Hearing impaired, Phonological disorder, etc.)

—

7/7/2011 34

It makes no logical sense that motor exercises could help improve the speech of children who have non-motor

Disorders that SLPs Use NSOME—Non-Motor Problems

speech of children who have non-motor problems, such as language-phonemic- phonological problems, like children in Early Intervention diagnosed as late talkers.

Why would children with a language-based sound

Disorders that SLPs Use NSOME—Non-Motor Problems

g g problem improve with a motor- based treatment approach?

NSOME and

Disorders that SLPs Use NSOME

Children with Dysarthria

Should NSOME be used for children with the diagnosis of

Disorders that SLPs Use NSOME—Dysarthria

dysarthria? What does the acquired dysarthria literature say?

“…strengthening exercises are probably only appropriate for a small number of patients ”

Disorders that SLPs Use NSOME—Dysarthria

number of patients.” “…weakness is not directly related to intelligibility..for patients with ALS.”

Duffy (2005)

Mackenzie, C., Muir, M., & Allen, C. (2010). Non-speech oro-motor exercise use in acquired dysarthria management:

Disorders that SLPs Use NSOME—Dysarthria

use in acquired dysarthria management: Regimes and rationales. International Journal of Language and Communication Disorders, 1-13.

7/7/2011 35 81% of SLPs in Scotland, Wales, and Northern Disorders that SLPs Use NSOME—Dysarthria Ireland, working with adult- acquired dysarthria, use NSOME

Mackenzie, Muir, & Allen (2010)

“That NSOME are appropriate in dysarthria is part of the folklore of SLT, and folklore may be a potent influence,

Disorders that SLPs Use NSOME—Dysarthria

and folklore may be a potent influence, even impending the adoption of approaches which have scientific validity, in favour of what is handed down by word

• f mouth or demonstration.”

Mackenzie, Muir, & Allen (2010)

Should NSOME be used for children with the diagnosis of dysarthria?

Disorders that SLPs Use NSOME—Dysarthria

Based on the adult acquired dysarthria literature, it appears that NSOME are not recommended as a technique that can improve speech productions.

Duffy (2005); Yorkston, Beukelman, Strand, & Hakel (2010)

Evidence Against NSOME

Evidence

Evidence Against NSOME

Based Practice

EBP

There are a limited number of Evidence Against NSOME published (peer reviewed) articles that have sufficient scientific rigor.

7/7/2011 36 ASHA National Center for Evidence-Based Practice in Communication Disorders

Evidence Against NSOME

Communication Disorders (NCEP)

Purpose:

To conduct evidence-based systematic reviews

• n NSOME

McCauley, Strand, Lof, Schooling, & Frymark, (2009)

ASHA National Center for Evidence-Based Practice in Communication Disorders (NCEP)

Findings:

Evidence Against NSOME

Based on the 8 published peer-reviewed articles, the evidence is equivocal due to the lack of well-designed experimentally controlled studies with adequate statistical power and adequate description of subjects.

McCauley, Strand, Lof, Schooling, & Frymark, (2009)

CONVINCING evidence that they do not work

Evidence Against NSOME

do not work NO real data that supports their use There is some research evidence, most of which has been presented at

Evidence Against NSOME

most of which has been presented at various ASHA Conventions…

RESEARCH: Non Speech Oral Motor Exercises

Do Not Work

1. Christensen & Hanson (1981) 2. Gommerman & Hodge (1995) 3. Colone & Forrest (2000) 4 Occhino & McCane (2001)

1 2 3 4 5 6

4. Occhino & McCane (2001) 5. Abrahamsen & Flack (2002) 6. Bush, Steger, Mann-Kahris, & Insalaco (2004) 7. Roehrig, Suiter, & Pierce (2004) 8. Guisti & Cascella (2005) 9. Hayes (2006)

• 10. Forrest & Iuzzini (2008)

7 8 9 10

1. Fields & Polmanteer (2002)

RESEARCH: Non Speech Oral Motor Exercises

Do Work

1

But this study has MANY methodological fatal flaws (more on this later)

7/7/2011 37 There are 11 studies il bl 10 th t h h

Evidence Against NSOME

available, 10 that have shown that NSOME were not effective as a treatment approach.

Evidence-Based Practice

Levels of Evidence from Studies

LEVEL Ib:

STRONG Well designed randomized controlled study

LEVEL Ia: STRONGEST Well-designed meta-analysis of >1 RCT LEVEL Ib: STRONG

Well-designed randomized controlled study

LEVEL IIa: MODERATE Well-designed controlled study without randomization LEVEL IIb: MODERATE Well-designed quasi-experimental study LEVEL IV: WEAK

Opinion of authorities, based on clinical experience

LEVEL III: LIMITED

Nonexperimental studies (i.e., correlational and case studies)

RESEARCH:

Non Speech Oral Motor Exercises Do Not Work

Christensen and Hanson (1981)

• 10 children
• Aged 5;8 to 6;9 years
• 14 weeks
• 14 weeks
• Half of the children received only articulation therapy; the other

half received articulation and “neuromuscular facilitation techniques”

• Both groups made equal speech improvements
• The exercises did not help for better speech sound production

BUT were effective in remediating tongue-thrusting (probably due to task specificity)

Gommerman & Hodge (1995)

• 16 year-old girl with tongue thrust and sibilant

distortions

RESEARCH:

Non Speech Oral Motor Exercises Do Not Work

• A Phase, no treatment; B Phase, myofunctional

treatment; C Phase articulation therapy.

• Tongue thrust was eliminated with myofunctional

therapy but speech was unchanged.

• With articulation therapy, sibilant productions

improved. Colone & Forrest (2000)

• Monozygotic twin boys age 8;11 year old
• Motor treatment for Twin 1, phonological

RESEARCH:

Non Speech Oral Motor Exercises Do Not Work

treatment for Twin 2

• NO improvements with motor training (Twin 1);

good results using a phonological approach (Twin 2)

• When Twin 1 received phonological treatment,

there were the same improvements as Twin 2 Occhino & McCane (2001)

• Single Subject Design (A-B-C-B-C)
• 5 year old child
• Results were that oral motor exercises alone

RESEARCH:

Non Speech Oral Motor Exercises Do Not Work

Results were that oral motor exercises alone produced no improvement in the articulation of one of two phonemes

• Also no improvements in oral motor skills
• Oral motor exercises prior to or along with articulation

therapy did not have an additive or facilitative effect

• Articulation improved with articulation therapy

7/7/2011 38

Abrahamsen & Flack (2002)

• Single Subject Design

4 year old child

RESEARCH:

Non Speech Oral Motor Exercises Do Not Work

• 4 year old child
• 10 hours of individual treatment
• Used blowing, licking, and oral stimulation
• No evidence of effectiveness in changing

speech-sound productions Bush, Steger, Mann-Kahris, & Insalaco (2004)

• ABAB Withdrawal Single Subject Design
• 9 year old boy

RESEARCH:

Non Speech Oral Motor Exercises Do Not Work

• 9 year old boy
• OME added to articulation treatment, then

removed, then re-added

• /r/ /s/ /z/ /l/
• “Oral motor treatment did not improve or reduce

treatment's success.” Roehrig, Suiter, & Pierce (2004)

• AB or BA Single Subject Design
• Six 3;6 - 6;0 boys and girls

RESEARCH:

Non Speech Oral Motor Exercises Do Not Work

• 15 weeks total Tx: (A) Tradition, production-based Tx twice

a week for ½ hour; (B) Passive OME and traditional Tx twice a week for ½ hour

• “The addition of OME to the traditional articulation therapy

approach did not add to participants overall progress; improvement following therapy with OME was not different from improvements following articulation therapy alone.”

Guisti & Cascella (2005)

• Single Subject Design using 2 boys and 2 girls
• All in first grade

RESEARCH:

Non Speech Oral Motor Exercises Do Not Work

• Followed Easy Does it for Articulation: An Oral

Motor Approach (1997)

• 15 ½ hour individual treatment sessions
• No evidence of effectiveness in changing speech-

sound productions Hayes (2006)

• Six 4 year olds, 5 boys and 1 girl
• All had “functional misarticulations”

C b l d i i d i bj

RESEARCH:

Non Speech Oral Motor Exercises Do Not Work

• Counterbalanced intervention design so subjects were

randomly assigned to a specific order; Oral motor approach and traditional articulation approach.

• The traditional treatment resulted in significant change; no

support for using oral motor for change.

• Some support that NSOME actually hindered learning.

Forrest & Iuzzini (2008)

• 9 children, 3;3 to 6;3 years
• Alternating treatment design: 1 sound treated with

NSOME 1 sound with production treatment (PT) 1 not

RESEARCH:

Non Speech Oral Motor Exercises Do Not Work

NSOME, 1 sound with production treatment (PT), 1 not treated

• At least 20 treatments sessions lasting 60 minutes
• RESULTS:

– 30% increase in sound accuracy with PT; 3% with NSOME – NSOME did not even improve movement control when assessed using a Volitional Oral Motor test

7/7/2011 39

Fields & Polmanteer (2002)

• Eight 3- to 6-year-old children
• Randomly assigned to one of two groups
• Four children received 10 minutes of oral motor

RESEARCH:

Non Speech Oral Motor Exercises Do Not Work

Four children received 10 minutes of oral motor treatment and10 minutes of speech therapy; four children received 20 minutes of only speech therapy

• Fewer errors at the end of 6 weeks of treatment for

the children who received the combination of treatments

BUT….

Fields & Polmanteer (2002)

Many methodological and statistical issues

• Severity distribution not equal (speech-only group

RESEARCH:

Non Speech Oral Motor Exercises Do Not Work

Severity distribution not equal (speech only group more severe)

• Gender distribution not equal
• The treated sounds and the equivalency of the

sounds between groups were not reported.

VERY Questionable Results

The evidence that is available…

OVERWHELMINGLY

Evidence Against NSOME

demonstrates that NSOME are not effective in bringing about speech-sound changes. Based on the findings as of now, th f NSOME t b

Evidence Against NSOME

the use of NSOME must be considered exploratory and the clients should be informed of this prior to initiating their use in therapy Recent Reviews of the Literature

Evidence Against NSOME

CLINICAL FORUM: The Use of Nonspeech Oral Motor Treatments for Nonspeech Oral Motor Treatments for Developmental Speech Sound Production Disorders: Interventions and Interactions

Language, Speech and Hearing Services in the Schools

July, 2008

Many SLPs use a combination of treatment approaches, so it is difficult to “tease apart” which approach is providing therapeutic

What about Combining Treatment Approaches?

benefit. Whenever intervention approaches are combined, it is unknown if and how they actually work in conjunction with each

• ther to enhance performance.

7/7/2011 40

There is much evidence that the NSOME portion of combined treatments is irrelevant to speech improvements. NSOME b bl d t h th hild h

What about Combining Treatment Approaches?

NSOME probably do not harm the child when used in combination with other approaches. SLPs should eliminate the approach that is not effective (i.e., NSOME) so as to not waste valuable therapy time with an ineffectual technique.

that are used in articulation therapy are

Phonetic Placement Cues Phonetic Placement Cues

articulation therapy are NOT the same as NSOME NSOME are a

NSOME are NOT Goals

procedure, NOT a goal!!!

Oral motor exercises are a procedure, NOT a goal!!!

The goal of therapy is NOT to produce a tongue wag to NSOME are NOT Goals to produce a tongue wag, to have strong articulators, to puff out cheeks, to blow “harder” horns, etc.

Oral motor exercises are a procedure, NOT a goal!!!

R th th l i t NSOME are NOT Goals Rather, the goal is to produce intelligible speech

Why Do SLPs Use NSOME? Some potential reasons why NSOME is used so frequently NSOME is used so frequently in the remediaton of speech sound disorders:

Lof (2008)

7/7/2011 41

 The procedures can be followed in a

step-by-step “cookbook” fashion The exercises are tangible with the

Why Do SLPs Use NSOME?

appearance that something therapeutic is being done at a physical level (even if the disorder is not motor in nature as would be the case for hearing impairment or phonological impairment)

 There is a lack of understanding the

theoretical literature addressing the dissimilarities of speech-nonspeech

Why Do SLPs Use NSOME?

p p movements The techniques can be written out to produce handouts to give to caregivers for use outside of the therapy setting  There are a wide variety of techniques and tools available that are attractively presented for purchase

Why Do SLPs Use NSOME?

 Many practicing clinicians do not read peer-reviewed articles but instead rely on unscientific writings (e.g., web sites, the popular press, marketed therapy tools, etc.) They attend non-peer reviewed activities (e.g., continuing education events) that encourage the use of these activities

Why Do SLPs Use NSOME?

encourage the use of these activities Parents and occupational/physical therapists on multidisciplinary teams encourage using NSOME Frequently, other clinicians persuade their colleagues to use these techniques, which is reminiscent of a statement by

Why Do SLPs Use NSOME?

which is reminiscent of a statement by Kamhi (2004) who stated, “…no human being is immune to hearing a not-so- good idea and passing it on to someone else.”

Been burned before….

Clinicians often resort to “because it works”

• bservations

Remember, we wrongfully embraced facilitated communication!!

7/7/2011 42

A Helpful Reference Nov., 2008

CLINICAL FORUM:

The Use of Nonspeech Oral Motor Treatments for

Another Helpful Reference…

Motor Treatments for Developmental Speech Sound Production Disorders: Interventions and Interactions

Language, Speech and Hearing Services in the Schools

July, 2008

What questions/comments do you have?

1

Updating Evidence Against Updating Evidence Against Nonspeech Oral Motor Exercises Nonspeech Oral Motor Exercises (NSOME) for Speech Sound (NSOME) for Speech Sound Productions Productions

Gregory L. Lof, PhD, CCC-SLP

Department Chair/Professor

July, 2011

Boston, MA