20Q: Non-Speech Oral Motor Treatments: Any evidence?

From the Desk of Ann Kummer

One of the most controversial subjects in the field of speech-language pathology is the use of non-speech oral motor exercises (NSOMEs) to improve speech disorders and even feeding and swallowing. NSOMEs do not involve direct work on speech sound placement or on feeding or swallowing. Instead, these exercises include unrelated oral motor activities, such as blowing bubbles and horns; tongue pushes, wags, and curling; lip-puckering and stretching; and other movements of the structures of the mouth. The assumption behind these exercises is that weak oral muscles or inadequate flexibility is the cause of these disorders. NSOMEs are promoted by many of our colleagues and especially by vendors who offer a wide variety of tools, gadgets, and techniques for purchase.

Although the use of these exercises is popular with many, the evidence for their efficacy and even the theoretical basis for their use is consistently lacking. In this era of “fake news,” fringe theories, and pseudoscience, it is more important than ever to consider the evidence before employing techniques that may be ineffective, costing our clients time and money with no real benefit.  Therefore, I am particularly excited to introduce Alice Lee, PhD to you. With this 20Q article, Dr. Lee will answer many of your questions about NSOMEs and the current evidence regarding the efficacy of these exercises for treatment.

Dr. Alice Lee is a speech-language therapist and Lecturer in Speech and Hearing Sciences at University College in Cork, Ireland. Her research interests and expertise include perceptual and instrumental investigations of speech disorders using electropalatography, acoustic analysis, and ultrasound.  She researches problems with resonance, articulation, and prosody in individuals with structural anomalies, such as cleft palate, and neurological impairment causing motor speech disorders. She is an author of the following systematic review on non-speech oral motor treatments: Lee, A. S. Y., Gibbon, F. E. (2015) Non-speech oral motor treatment for children with developmental speech sound disorders (Review), Cochrane Database of Systematic Reviews 2015, Issue 3. Dr. Lee has served as the Editor of Journal of Clinical Speech and Language Studies, the official journal of the Irish Association of Speech and Language Therapists (2010-2019) and she currently serves as the Section Editor for Speech Pathology for The Cleft Palate-Craniofacial Journal.

I think this is a particularly important topic for all of us and this article is certainly thought-provoking!

Now…read on, learn, and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Contributing Editor 

Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q

20Q: Non-Speech Oral Motor Treatments: Any evidence?

Alice Lee

1. There have been controversies about using non-speech oral motor treatments in speech therapy. So, first of all, what are non-speech oral motor treatments?

The most cited definition of non-speech oral motor treatments is probably the one stated in the systematic review by McCauley and colleagues published in 2009. This paper reports an evidence-based systematic review supported by the National Center for Evidence-Based Practice in Communication Disorders (N-CEP) of the American Speech-Language-Hearing Association (ASHA). The authors defined oral motor exercises as “nonspeech activities that involve sensory stimulation to or actions of the lips, jaw, tongue, soft palate, larynx, and respiratory muscles that are intended to influence the physiological underpinnings of the oropharyngeal mechanism to improve its functions. They may include activities described as active muscle exercise, muscle stretching, passive exercise, or sensory stimulation” (McCauley et al., 2009, p. 334).

2. Are there any other definitions that have been mentioned in the literature?

Yes, other definitions have been provided and some also included a few typical examples of the tasks used in this treatment approach. For example, Hodge (2002, p. 22) stated that “the term oral motor treatment refers to a range of nonspeech and speech-like activities used to achieve a variety of goals that involve actions of the lips, jaw, and tongue”. Lof (2008, p. 253) explained that “NSOMEs [nonspeech oral motor exercises] can be defined as any therapy technique that does not require the child to produce a speech sound but is used to influence the development of speaking abilities”. And Lass and Pannbacker (2008, p. 408) described that “nonspeech oral motor treatments (NSOMTs) focus on nonspeech movements of the speech mechanism such as exercise, blowing, positioning, icing, swallowing, and other nonspeech activities”.

3. Are there any more recent discussions of the definition?

Yes, there is a fairly recent paper by Kent (2015), where he used the term “nonspeech oral movements” (NSOMs) and defined it as the “motor acts performed by various parts of the speech musculature to accomplish specified movement or postural goals that are not sufficient in themselves to have phonetic identity” (p. 765).

4. There seem to be some differences between these definitions, is that right?

Yes, and this was pointed out in Kent’s paper, that the definition used in the systematic review by McCauley and colleagues “does not explicitly exclude speech behaviors of any kind” (Kent, 2015, p. 766). And if the non-speech tasks refer to those that do not involve the production of speech sounds (e.g. the definition used in Lof, 2008), then “a host of research and clinical procedures such as imagined, covert, or mouthed speech” would be considered as non-speech oral motor tasks (Kent, 2015, p. 766). Hence, he offered definitions and taxonomies for speech and non-speech movements and discussed the distinctions between non-speech oral motor movements, speechlike, quasispeech or paraspeech, nonword repetition, speech. These are important when evaluating the application of NSOMs in assessment and intervention (Kent, 2015).

5. So far, I heard you mentioned a few variations of the name of this treatment approach. So, what kind of terms have been used in the literature?

The key constituent is “oral motor”, so previously it has been known as “oral motor exercises”, “oral motor therapy”, or “oral motor intervention”. The terms, “myofunctional therapy” or “orofacial myofunctional therapy”, have been used as well. The term with “non-speech” (or “nonspeech”) added to it has been used in the past couple of decades or so; perhaps, to differentiate this approach from the others that employ speech production tasks in speech intervention. Kent (2015) used the term, “nonspeech oral movements”, and this term does not limit to those that are used in intervention.

6. Which clinical areas have NSOMTs been applied to?

As reviewed by Kent (2015), it has been applied to “developmental speech and language disorders, motor speech disorders, drooling, feeding and swallowing difficulties, orofacial myofunctional disorders, obstructive sleep apnea, trismus, and tardive stereotypies” (p. 763). Lass and Pannbacker (2008) also mentioned “cleft palate, … autism, voice disorders, … and hearing loss” (p. 412). Similar information was reported in other papers as well.

7. What are the arguments for using NSOMTs in general?

There are a few assumptions for NSOMTs (see Bunton, 2008; Clark, 2010; Lee & Gibbon, 2015; Ruscello, 2008). The first main assumption is that there is a common set of motor control principles and neural anatomical representation in the human nervous system for speech and non-speech activities that involve the same structures. Hence, for example, movement characteristics and task demands for the production of bilabial speech sounds and those for blowing bubbles or horns are presumably similar, and the training effect caused by practicing blowing bubbles or horns could be transferred to the production of bilabial sounds. Another assumption is based that learning could be facilitated by breaking down complex movements into subcomponents because this allows “the motor system to plan simpler movement patterns and gradually develop skilled control of more complex movement patterns” (Clark, 2010, p. 586). Hence, for example, to treat a child with a speech error for the sound /s/, exercises for establishing jaw stability, tongue stability, elevation of the lateral sides of the tongue, elevation of the tip of the tongue and so on are used (Marshalla, 2000).

8. And what are the arguments against using NSOMTs?

Lof and Watson (2010) summarized the arguments about why NSOMTs do not work. First, isolated training of individual speech movements will not generalise to the whole articulatory gesture. Second, NSOMTs are not useful for improving muscle strength because it has been shown that high muscular strength is not required for producing speech. Moreover, reduced speech intelligibility and speech sound errors are not caused by reduced muscular strength of the articulators. Third, previous studies have demonstrated that neural organization for speech and non-speech tasks can be different, even though the same oral structures are involved in those speech and nonspeech tasks. Fourth, NSOMTs for the purpose of warming up muscles or increasing children’s awareness of their articulators are not useful or necessary because speaking does not tax the muscular system.

9. Do we have any statistics about the usage of NSOMTs by speech-language pathologists (SLPs) or speech and language therapists (SLTs)?

There are a number of published studies that reported the information and it is summarised very generally in the table below. As shown by the results of these surveys, the percentage of SLPs or SLTs who reported having used NSOMTs, whether it is frequently or infrequently, seems to vary between countries and depending on the client group or the type of speech difficulties of the clients. For example, it seems that adults with acquired dysarthrias is the group with which more clinicians have used NSOMTs. A very recent study that used focus group discussion with 62 SLT professionals in the UK also reported the use of NSOMTs as one of the intervention approaches with preschool children with repaired cleft palate (Williams, Harding, & Wren, 2020); however, the information on how many of those SLT professionals have used this intervention approach was not available. For the two surveys carried out in the US, there seems to be a trend of decreased percentage of clinicians who reported having used NSOMTs; however, further investigation is needed in order to make a more definite conclusion.

10. For those who have used NSOMTs, what kind of tasks have been used?

Four of the surveys stated above reported that information and in general the findings are quite similar, with tasks that involve the lips, such as “lip rounding”, “pucker-smile alternations”, and “blowing”, being used by the majority of clinicians, following by tasks that involve the tongue, such as “tongue lateralization” and “tongue push-ups” (Lee & Moore, 2014; Lof & Watson, 2008; Rumbach et al., 2019; Thomas & Kaipa, 2015).

11. Why did they use NSOMTs?

For most of the respondents, they used NSOMTs (1) for improving the clients’ awareness of articulators and/or the strength and range or movement of the articulators (Rumbach et al., 2019; Thomas & Kaipa, 2015); (2) as “warm-up” (Lee & Moore, 2014; Lof & Watson, 2008); or (3) because of the positive results from the clinical experience of their own or their colleagues, and high level of exposure to related products (Hodge et al., 2005; Mackenzie et al., 2010).

12. How did they use NSOMTs – did they use it as the only intervention approach, or as an adjunctive treatment?

NSOMTs were usually used in combination with other speech intervention approaches or used as home practice or optional therapies (Joffe & Pring, 2008; Lee & Moore, 2014; Lof & Watson, 2008; Rumbach et al., 2019).

13. What is the evidence of NSOMTs for treating feeding and swallowing?

There is a systematic review on this topic carried out by Arvedson and colleagues (2010), which was also supported by the N-CEP of ASHA, for preterm infants. This review included 12 treatment studies of different research designs, published in English in peer-reviewed journals between 1960 and 2007. The review authors concluded that, although some of the oral motor interventions showed positive results in improving some of the feeding and swallowing variables, a clear conclusion on the efficacy of the intervention approach could not be made due to the methodological limitations in the included studies. There is no systematic review for children of other age groups and adults, but Kent (2015) gave a literature review. Similarly, there is limited evidence that shows the efficacy of NSOMTs for improving swallowing function for adults (Kent, 2015).

14. What about the evidence of NSOMTs for treating dysarthrias?

A review of the relevant literature is available in the papers by Hodge (2002) and Kent (2015). Hodge (2002) identified one case study, 12 studies of cases reviewed in a book and a book chapter, one case reported in an anecdotal report and two in a newsletter – all published between 1960 and 2002. These cases were adults with acquired dysarthrias. Kent (2015) reviewed the inclusion of NSOMEs as a component in intervention approaches that target respiratory/phonatory function, and orofacial muscles. Altogether, although positive effects on speech were reported in some of these studies, the current evidence is insufficient to support the efficacy of NSOMTs for treating dysarthrias.

15. How about NSOMTs for treating children with a history of cleft palate?

For this group of clients, there is a very recent review of literature carried out by Ruscello and Vallino (2020). They reviewed the literature on the neurophysiological relationship between speech and nonspeech tasks, treatment studies that used NSOMTs, and relevant systematic reviews. The authors concluded that “there is no empirical support for the use of NSOME as a direct or adjunct treatment for velopharyngeal dysfunction or compensatory speech errors” (p. 1811).

16. How about NSOMTs for treating speech sound disorders in children?

There are four systematic reviews that addressed this topic (Lass & Pannbacker, 2008; Lee & Gibbon, 2015; McCauley et al., 2008; Ruscello, 2010). Although there were some differences in the search strategies between these systematic reviews, the findings were consistent in that there is no sufficient evidence to support the efficacy of NSOMTs for treating children with speech sound disorders due to the methodological limitations (e.g. small sample size, insufficient description of protocols) evident in the included studies.

17. In terms of speech evaluation, many non-speech oral motor tasks are used as part of an assessment protocol, such as those used in an oral peripheral exam. So, what is the latest view regarding the value of these tasks in speech assessment?

It is true that there is quite a long history of including non-speech tasks as part of an assessment protocol, especially in those for motor speech disorders. The latest view is that, when used with assessment tasks that evaluate speech production, these tasks of NSOMs are useful for investigating the nature and the severity level of neurological abnormalities of the clients (Kent, 2015).

18. There is an increasing application of motor learning theory in motor-based articulation therapy. How does that link to the topic that we are discussing here?

The rationale of applying motor learning theory in speech intervention is that speech production is a motor skill, so perhaps some of the principles that enhance the learning of motor skills in other domains, such as non-speech motor skills, can provide insights to the learning of speech motor skills (Maas et al., 2008). This is different from using a non-speech task for treating the production of a certain speech sound. What it means is, for example, if a large number of practice trials is useful for learning a non-speech motor skill, similar principle might work for learning a speech motor skill. In the paper by Maas and colleagues, they reviewed the variables related to the structure of practice and augmented feedback that can enhance the learning of non-speech and speech motor skills. For the structure of practice, they include the amount, distribution, variability, and schedule of practice, attentional focus, and movement complexity. For the structure of feedback, they include the type, frequency, and timing of feedback (Maas et al., 2008).

19. If we would like to do some further readings on this topic, are there any references that you could recommend?

Yes, I would suggest starting with the series of papers published as a clinical forum on NSOMTs in the journal, Language, Speech, and Hearing Services in Schools in 2008 (volume 39, issue 3) and the special issue, “Controversies surrounding nonspeech oral motor exercises for childhood speech disorders”, published in the same year in the journal, Seminars in Speech and Language (volume 29, issue 4). I would also suggest reading the systematic reviews mentioned above (Arvedson et al., 2010; Lee & Gibbon, 2015; McCauley et al., 2009) and the recent narrative review by Kent (2015); as well as other articles or book chapters (e.g. Bowen, 2005; Clark, 2010; Lof, 2009; Lof & Watson, 2010).

20. What is the final message for our audience regarding the current topic?

As discussed, there is still insufficient evidence that supports the efficacy of NSOMTs for treating speech and swallowing function. So, the use of this treatment approach should be avoided until concrete evidence is available. As pointed out by Ruscello and Vallino (2020), using treatment for which the efficacy is unclear can be costly to both patients and clinicians in terms of money, time and resources. Finally, as discussed by Kent in his paper (2015), a variety of tasks that involve speech production, speech-like activities, and non-speech movements have been used in research and treatment; and the similarities (or differences) between them in terms of neural control and muscles deployed varies to different extent. Future research that investigates the efficacy of NSOMTs, or the link between speech and non-speech movements should go beyond 'description of oral structures and movements involved only’. Further account of those tasks by applying, for example, the definitions and taxonomies detailed in Kent (2015) would us better in evaluating the value of these tasks in speech assessment and intervention.

References

Arvedson, J., Clark, H., Lazarus, C., Schooling, T., & Frymark, T. (2010). Evidence-based systematic review: Effects of oral motor interventions on feeding and swallowing in preterm infants. American Journal of Speech-Language Pathology, 19(4), 321-340. doi:10.1044/1058-0360(2010/09-0067)

Bowen, C. (2005). What is the evidence for oral motor therapy? Acquiring Knowledge in Speech, Language and Hearing, 7(3), 144–147.

Bunton, K. (2008). Speech versus nonspeech: Different tasks, different neural organization. Seminars in Speech & Language, 29(4), 267-275. doi:10.1055/s-0028-1103390

Brumbaugh, K. M., & Smit, A. B. (2013). Treating children ages 3-6 who have speech sound disorder: A survey. Language, Speech, and Hearing Services in Schools, 44(3), 306-319. doi:10.1044/0161-1461(2013/12-0029)

Clark, H. M. (2010). Nonspeech oral motor intervention. In A. L. Williams, S. McLeod, & R. J. McCauley (Eds.), Interventions for speech sound disorders in children (pp. 579-599). Baltimore, MD: Paul H. Brookes Publishing.

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Ruscello, D. M. (2010). Collective findings neither support nor refute the use of oral motor exercises as a treatment for speech sound disorders. Evidence-Based Communication Assessment and Intervention, 4(2), 65-72. doi:doi.org/10.1080/17489539.2010.501168

Ruscello, D. M., & Vallino, L. D. (2020). The use of nonspeech oral motor exercises in the treatment of children with cleft palate: A re-examination of available evidence. American Journal of Speech-Language Pathology, 29(4), 1811–1820. doi:10.1044/2020_AJSLP-20-00087

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Williams, C., Harding, S., & Wren, Y. (2020). An exploratory study of speech and language therapy intervention for children born with cleft palate ± lip. Cleft Palate-Craniofacial Journal. Advance online publication.