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#62  The Importance of Interpretation [Are references always accurate?]

Season’s Greetings SLP! 

“EBP creates an interesting predicament because the efficacy of NSOMEs has been questioned based both on empirical data and on the basic underlying assumptions for their use (Clark, 2003, 2005; Forrest, 2002; Kamhi, 2006; Lof, 2003).”  

Lof and Watson wrote the above in their 2008 survey article (p. 393).  As you read, they specifically listed five references as a base to their “NSOME” concerns and criticisms.

So, I zeroed-in on those five documents and read them very carefully.  I anticipated reading therapy studies that used arbitrary NSOMEs with detrimental results, or, solid, unequivocal documentation that questioned their use.

I found neither; not even close.

My interpretation of the articles is very different from theirs.

Bottom line:

  • In the five articles there are no controlled studies and there is only brief reference to the types of arbitrary activities that Dr. Lof referred to.
  • None of the resources (except for Lof's article) used the term NSOME.
  • They expressed minimal concerns and questions about oral motor use, as well as concerns about other therapy techniques.
  • I also read positive and detailed descriptions of how to do oral motor tasks with individuals with motor-based disorders (e.g. activities that may be effective with adult apraxia, dysarthria, and dysphagia).

This is the foundation of the anti-oral motor evidence base?  There are other articles put forward by Dr. Lof and a few others at later dates that disparage oral motor, but Lof’s 2008 survey article was one of the first and has been widely quoted and cited.

Below, I review the first four above mentioned references.  The fifth reference is Dr. Lof’s own 2003 article published in The ASHA Leader.  It contains the controversial and inconclusive theoretical areas that he has continued to state since 2008. (I address these, e.g. task specificity, relevancy, sensation, etc., in #4 The Perfect Oral Motor Storm.  Also, I’ll devote future Therapy Matters to these topics.)   

Let’s see what they have to say. 

1. Heather Clark, 2003, Neuromuscular Treatments for Speech and Swallowing: A Tutorial

In my opinion, Dr. Clark is the go-to researcher (and therapeutic instructor) for working with known oral muscle impairments—acquired apraxia, dysarthria, and dysphagia.  In this 2003 tutorial article, in reference to evidence-based practice and therapy, she explains: 

“At least two strategies are available to clinicians selecting management techniques for specific individuals:  The approach that is advocated by evidence-based practice is to refer to research reports describing the benefits of a particular treatment.  The question asked in this case is, ‘Is this treatment beneficial?’  In the absence of adequately documented clinical efficacy, clinicians may select treatments based on theoretical soundness.  The question asked in this case is, ‘Should this treatment be beneficial?’  This second method of treatment has potential for success if the clinician has a clear understanding of both the nature of the targeted impairment and the therapeutic mechanism of the selected treatment technique.

My interpretation:  As therapists, we must not only understand our client’s disorder, but what we do must be based in reliable theory and competently applied as it relates to our client’s disorder. Makes sense; good goal.  

For the remainder of the article, she tutors us on muscles and muscle impairments (weakness and disrupted muscle tone), as well as neuromuscular treatments (active exercises and passive exercises).  It’s an excellent article.  I read no pessimism here. 

2. Heather Clark, 2005, Clinical Decision Making and Oral Motor Treatments (an ASHA Leader Article) 

This more informal ASHA Leader article is similar to her 2003 journal article.  Toward the beginning, she states: 

“Although the rationale for adopting oral motor techniques varies depending on the specific techniques and the clients for whom they are selected, I believe a basic philosophy leads to the adoption of any oral motor treatment.  That is, we know that speech and swallowing are motor behaviors (i.e., they involve movement) and that disrupted or immature movement control may interfere with speech and swallowing effectiveness.  
Accordingly, we might expect that alleviating underlying motor impairments or facilitating motor system development will bring about improved speech and swallowing function.  For this philosophy to lead to sound clinical decision-making, clinicians must have a thorough understanding of the nature of neuromuscular impairments as well as the treatments purporting to address such impairments.
 

Again, she wants SLPs to have a rationale base.  Fair enough. 

She continues to enlighten us about muscle strength, tone, and endurance, as well as assessment, impact of impairments, and treatments.  Very informative.  Since that time, she has written other helpful articles on working with muscles. 

3. Forrest, 2002, Are Oral-Motor Exercises Useful in the Treatment of Phonological / Articulatory Disorders?

Dr. Forrest was one of the first to “review the extant [existing] studies of the relation between oral-motor exercises and speech production in children as well as to examine the motor learning literature to gain a broader perspective on the issue.”  She states, 

“[There is] limited published evidence of the relationship of oral-motor proficiency and phonological/articulatory disorders (PAD) remediation….”  In her oral-motor review, she cited “only articles that included experimental controls….”  She cites two, and they both focused on myofunctional therapy for tongue thrust and /s/ (Overstake, 1976; Christensen and Hanson, 1981; we’ll review the latter article in a future Therapy Matters).  Both articles reported positive results.  
“Clearly there is a need for more experimental studies of the effect of nonspeech oral-motor treatment on changes in speech production.”  In fact, she was true to her word.  She and Iuzzini-Seigel did their comparison study in 2008.  (See, #56, Therapy Matters.) 

She also investigated studies on motor learning:  Part-whole speech training, the use of strengthening tasks with children in therapy, and the use of normal development patterns as a therapy guide.  These also happen to be three of Dr. Lof’s concerns.  I am unaware as to who initiated these talking points first—Dr. Forrest or Dr. Lof.  It probably doesn’t matter; they are coordinated in their printed views, however.  I address these concerns and others, in #4 of The Perfect Oral Motor Storm, and discuss the fallacies of their views and statements. 

4. Kamhi, 2006, Treatment Decisions for Children with Speech-Sound Disorders

Dr. Kamhi’s article reads like a newsy “official” blog on evidence-based practice (EBP) that was perhaps motivated by the induction of EBP: “I came to see that EBP was much more than simply using research to guide clinical practice.”  Good point.  He continues: 

“…There are several myths that have become associated with EBP.  EBP is not simply using an intervention approach that has research support.  EBP is the integration of the best research with clinical expertise and client values.”  I agree. 
“Another myth about EBP concerns the nature of the evidence required to support a treatment approach.”  For example, he cites Ylvisaker (2004), “…the strongest evidence for a clinical decision is experimental validation with the particular client.  This evidence could come in the form of trial therapy, diagnostic teaching, or dynamic assessment.”  

Ylvisaker’s statement reminds me of Dr. Lof’s survey results: 92.7% of the SLPs stated that they had observed improved nonspeech oral motor skills, and 86.3% had observed improved speech productions. 

Insightfully, Dr. Kamhi says that making treatment decisions is not easy.  “There is no simple prescription for choosing an intervention approach because clinical expertise and client values will vary.” 

The remainder of the article is divided into nine sections.  One section “Theoretical Perspectives” includes three paragraphs on the oral motor approach (that’s out of seven full pages).  Following are two excerpts; he reiterates Forrest’s, 2002 position: 

“The use of oral motor exercises is based on the assumption that poor oral motor control and/or strength contributes to poor articulation and that the complex motor coordination required for speech can be facilitated by breaking down this complex behavior into smaller units."  

This is the “part-whole speech training” concern that, in my reading and research reviews is absolutely ludicrous and unfounded.  It just means that speech cannot be parsed into components, combined, and taught.  (This is addressed and refuted with evidence in #4 of The Perfect Oral Motor Storm.) 

Dr. Lof also says that part-to-whole instruction is not effective.  I beg to differ; it is supported throughout the literature: “Part-task procedures are intended to improve learning efficiency,”(Wightman and Lintern, 1985.) 

Lastly, Dr. Kamhi cites concern over lack of evidence supporting the use of oral motor exercises.  He also cites Clark, 2003; Forrest, 2002; and Tyler, 2005.  Tyler, 2005, is an article about preschoolers, phonology, and language disorders.  (Clark’s and Forrest’s articles were discussed in the above pages.) 

The above four articles represent the extremely weak (close to non-existent) research foundation that Drs. Lof and Watson put forward in their 2008 survey article.  

Where is the referenced empirical evidence against the use of oral motor therapy, or their term, NSOMEs?  I didn’t see it. 

Where are the underlying assumptions?  Dr. Lof may be referring to the issues he stated in his own 2003 ASHA Leader Article about muscle strength, part-whole therapy, task specificity, etc.  These are inconclusive, unsubstantiated, debatable issues that he continues to put forward as fact.

Where’s the huge controversy? 

There have been and continue to be MANY MISCONCEPTIONS about oral motor. 

You who receive Therapy Matters are in a select group.  Most of you support physiologically-based therapy.  And if you don’t—that’s okay, do what works for you—I’m glad you’re here.  Thank you for your comments, yay or nay.  Also, if you would, please share the blogs with your colleagues.  I appreciate you all so very much. 

Have a great week—we’re closing in on the holidays! 

Char

 

Resources 

Christensen, M., and Hanson, M.  (1981).  An investigation of the efficacy of oral myofunctional therapy as a precursor to articulation therapy for pre-first grade children.  J of Sp and Hear Disorders, 46,160-167. 

Clark, H. (2003).  Neuromuscular treatments for speech and swallowing:  A tutorial.  Amer J of Sp-Lang Path, 12, 400-415. 

Clark, H. (2005, June 14).  Clinical decision making and oral motor treatments.  The ASHA Leader,pp.8-9, 34-35. 

Forrest, 2002, Are Oral-Motor Exercises Useful in the Treatment of Phonological / Articulatory Disorders? 

Kamhi, A.G.  (2006).  Treatment decisions for children with speech-sound disorders.  Lang Sp and Hear Servs in Schools, Vol 37, 271-279. 

Lof, G.L. (2003, April 1).  Oral motor exercises and treatment outcomes.  Perspectives on Language, Learning, and Education, 10 (1), 7-12.  (A no-access ASHA article) 

Lof, G.L., Watson, M.M.  (2008).  A nationwide survey of nonspeech oral motor exercises use:  Implications for evidence-based practice.  Lang Sp and Hear Services in Schools, Vol 39,392-407. 

Overstake, C.  (1976).  Investigation of the efficacy of a treatment program for deviant swallowing and allied problems.  International Journal of Oral Myology, Vol 2(1),1‐6.

Ylvisaker, M. (2004, November).  Evidence-based practice and rational clinical decision making. Paper presented at the Evidence-Based Practice in Child Language Disorders Working Group, Austin, TX.

 

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