Controversies Surrounding Nonspeech Oral Motor Exercises for Childhood Speech Disorders

The use of nonspeech oral motor exercises (NSOMEs) for influencing children's speech sound productions is a common therapeutic practice used by speech-language pathologists (SLPs) in the United States,[1] Canada,[2] and the United Kingdom.[3] Reports from these countries have documented that between 71.5% and 85% of practicing clinicians use some type of NSOMEs in therapy to change children's speech productions.

NSOMEs can be defined as any therapy technique that does not require the child to produce a speech sound but is used to influence the development of speaking abilities.[1] The National Center for Evidence-Based Practice in Communication Disorders (NCEP)[4] of the American Speech-Language-Hearing Association (ASHA) developed this definition: “Oral-motor exercises are activities that involve sensory stimulation to or actions of the lips, jaw, tongue, soft palate, larynx, and respiratory muscles which are intended to influence the physiologic underpinnings of the oropharyngeal mechanism and thus improve its functions; oral-motor exercises may include active muscle exercise, muscle stretching, passive exercise, and sensory stimulation.”

The term “oral motor,” which relates to movements and placements of the oral musculature, is established in the field of SLP. Although the existence and importance of the oral-motor aspects of speech production is well understood, the use and effectiveness of nonspeech oral-motor activities is disputed because of the lack of theoretical and empirical support.

To understand more about the use of NSOMEs for changing disordered productions of speech, a colleague and I[1] conducted a nationwide survey of 537 practicing clinicians from 48 states. We found that SLPs frequently used the exercises of blowing, tongue wagging and pushups, cheek puffing, the alternating movement of pucker-smile, “big smile,” and tongue-to-nose-to-chin. The clinicians believed these NSOMEs would help their clients obtain tongue elevation, protrusion, and lateralization; increase their tongue and lip strength; become more aware of their articulators; stabilize the jaw; control drooling; and increase velopharyngeal and sucking abilities. The respondents to the survey reported using these techniques for children with a wide variety of different speech disorders stemming from a wide variety of etiologies: dysarthria, childhood apraxia of speech (CAS), Down syndrome, late talkers, phonological impairment, functional misarticulations, and hearing impairment.

It makes one curious why clinicians would select these nonspeech therapeutic techniques because they lack adequate theoretical underpinnings for their use. Additionally, the research studies that have evaluated treatment efficacy using the NSOME techniques, although admittedly scant and not at the highest levels of scientific rigor, do not show therapeutic effectiveness. Not only are these nonspeech tasks lacking in theoretical and data support for their use, their application to improve speech intelligibility also often defies logical reasoning. So why do clinicians use these techniques?

As I have previously pointed out,[5] SLPs have several possible reasons for using NSOMEs. Some of these reasons may be that the procedures can be followed in a step-by-step “cookbook” fashion; the exercises are tangible with the 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 of the theoretical literature addressing the dissimilarities of speech-nonspeech movements; the techniques can be written out on handouts for caregivers to use outside of the therapy setting; a wide variety of techniques and tools are available that are attractively presented for purchase; many practicing clinicians do not read peer-reviewed articles but instead rely on unscientific writings (e.g., websites, 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; parents and occupational/physical therapists on multidisciplinary teams encourage using NSOMEs; and frequently other clinicians persuade their colleagues to use these techniques, which is reminiscent of a what Kamhi[6] said: “[N]o human being is immune to hearing a not-so-good idea and passing it on to someone else” (p. 110).

The logic, theory, and evidence against using NSOMEs have been addressed elsewhere[7] [8] [9]; this issue expands on why these nonspeech techniques need to be questioned by scientific clinicians if their purpose is to change erred speech sound productions in their clients. In this issue of Seminars in Speech and Language, leading research clinicians address several of the topics typically involved in the NSOME controversy.

To begin this issue, the topic is task specificity (the concept that “speech is special”). How the movements of the articulators for speech differ from movements for nonspeech are addressed. Wilson et al discuss the early oral behaviors of children and how these behaviors (e.g., chewing, sucking) have little relation to speech. Bunton takes on the topic of task specificity by reviewing the differences in the neurological basis of speech and for nonspeech movements, which precludes the transfer of skills obtained from the nonspeech task to the actual speaking task.

Many SLPs believe that children with speech sound disorders need to strengthen their articulatory muscles, which research has refuted.[10] [11] In fact, Sudbury et al[12] found that children with speech sound disorders actually had stronger tongues than did children without speech problems. In Clark's article, she elaborates on the role of strengthening exercises, also pointing out how targeting increased strength in therapy probably is not beneficial for improving speech accuracy.

Clinicians frequently use NSOMEs as a remediation task for children with disparate etiologies for their speech sound disorders. I[13] have previously written how children with the diagnosis of CAS are a population who would not benefit from such nonspeech drills. McCauley and Strand expand on this and add information on ways to work with children with CAS. Children in other diagnostic categories also are treated inappropriately with nonspeech tasks. Ruscello reviews how these NSOMEs are regularly used in the attempt to improve the velopharyngeal closure mechanism for a child with velopharyngeal inadequacy. He concludes that these tasks are ineffective in changing the closing mechanism for speech. Another group of children who are routinely provided NSOMEs are those who have been diagnosed as late talkers or children who are slow to develop first words. Davis and Velleman address how clinicians can promote the development of first words using “means, motive, and opportunity,” which are not dealt with when using NSOMEs.

Research studies have been conducted on the efficacy of nonspeech tasks, and these studies do not support the use of NSOMEs to change speech sound productions (for a summary of these studies, see Lof,[8] Ruscello,[14] Lass and Pannbacker[15]). Forrest and Iuzinni report on findings from their study, one that compares a traditional production treatment approach to NSOMEs for nine children with speech disorders. Their findings are consistent with prior research that shows the benefits of production training and the lack of benefits of NSOMEs.

Because the evidence-based paradigm is important for a clinical field such as speech-language pathology, as clinicians we need to know “what does work” in therapy based on the available research. Tyler reviews the literature on which therapeutic techniques, tested with well-designed methodologies, are efficacious for bringing about speech sound changes.

Finally, the last two articles tie this issue together. Kamhi uses the concepts of a “meme” and “memeplex” to help us understand why NSOMEs have become so embedded into the culture of speech-language pathology. Watson and I summarize all the articles in this issue, outlining the “take-home” message, and emphasize how clinicians must use logic, theory, and evidence to guide their practice.

I hope you find this series of articles helpful in sorting out the many different ideas that surround the controversial topic of NSOMEs to change children's speech sound productions.

REFERENCES

• 1 Lof G L, Watson M. A nationwide survey of non-speech oral motor exercise use: implications for evidence-based practice.  Lang Speech Hear Serv Sch. 2008;  39 392-407
• 2 Hodge M, Salonka R, Kollias S. Use of nonspeech oral-motor exercises in children's speech therapy. Poster presented at: the annual meeting of the American Speech-Language-Hearing Association November 2005 San Diego, CA;
• 3 Joffe V, Pring T. Children with phonological problems: a survey of clinical practice.  Int J Lang Commun Disord. 2008;  43 154-164
• 4 Arvedson J, Clark H, Frymark T et al.. The effectiveness of oral-motor exercises: an evidence-based systematic review. ASHA's National Center for Evidence-Based Practice in Communication Disorders. Paper presented at: the annual meeting of the American Speech-Language-Hearing Association November 2007 Boston, MA;
• 5 Lof G L. The nonspeech-oral motor exercise phenomenon in speech pathology practice. In: Bowen C Children's Speech Sound Disorders. Chichester, UK; John Wiley In press
• 6 Kamhi A. A meme's eye view of speech-language pathology.  Lang Speech Hear Serv Sch. 2004;  35 105-111
• 7 Lof G L. Oral motor exercises and treatment outcomes.  Perspectives on Language, Learning and Education. 2003;  10(1) 7-12
• 8 Lof G L. Logic, theory and evidence against the use of non-speech oral motor exercises to change speech sound production. Paper presented at: the annual meeting of the American Speech-Language-Hearing Association November 2006 Miami Beach, FL;
• 9 Lof G L. Reasons why non-speech oral motor exercises should not be used for speech sound disorders. Paper presented at: the annual meeting of the American Speech-Language-Hearing Association November 2007 Boston, MA;
• 10 Wenke R J, Goozée J V, Murdoch B E, LaPointe L L. Dynamic assessment of articulation during lingual fatigue in myasthenia gravis.  J Med Speech-Lang Pathol. 2006;  14 13-32
• 11 Bunton K, Weismer G. Evaluation of a reiterant force-impulse task in the tongue.  J Speech Hear Res. 1994;  37 1020-1031
• 12 Sudbery A, Wilson E, Broaddus T, Potter N. Tongue strength in preschool children: measures, implications, and revelations. Poster presented at: the Annual Meeting of the American Speech-Language-Hearing Association November 2006 Miami Beach, FL;
• 13 Lof G L. What does the research report about non-speech oral motor exercises and the treatment of speech sound disorders?. 2004. Available at http://www.apraxia-kids.org/site/c.chKMI0PIIsE/b.980831/apps/s/content.asp?ct=464461 Accessed November 10, 2008
• 14 Ruscello D. Nonspeech oral motor treatment issues related to children with developmental speech sound disorders.  Lang Speech Hear Serv Sch. 2008;  39 380-391
• 15 Lass N, Pannbacker M. The application of evidence-based practice to oral motor treatment.  Lang Speech Hear Serv Sch. 2008;  39 408-421