Rehabilitative Feeding and Speech Techniques for Teens and Adults
It Is Not Too Late!
Relevant financial relationship; No relevant non-financial relationship !
My name is Sara Rosenfeld-Johnson and I’m speaking on treating clients with speech oral placement disorders. I am an employee and patent holder of TalkTools. TalkTools is a company that manufactures tools and programs for Oral Placement Therapy. My job is to develop, research and write directions for the use of these tools. I have no relevant non-financial relationships to disclose.
Presented by Sara Rosenfeld-Johnson, M.S., CCC-SLP !
!
Author of: Oral Placement Therapy for Speech Clarity and Feeding Assessment and Treatment of the Jaw Oral Placement Therapy (OPT) for /s/ and /z/ and
“A Therapist’s Guide to REHABILITATIVE FEEDING AND SPEECH TECHNIQUES FOR TEENS AND ADULTS”
Case Study: Matt - Birth Date: May 22,1988
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
What is Oral Placement Therapy for Speech Clarity and Feeding Safety ?
December 2005: Car Accident - coma 3 months - Age:17 !
April 2006: Released from hospital to outpatient Rehab. !
June 11, 2008: Age: 20 - Initial Oral Placement for Feeding and Speech Evaluation in Tucson, Arizona - Non-verbal using a touch and type augmentative system to communicate in complete sentences. “Traumatic Brain Injury with right sided paresis resulting in weakness in the muscles of the abdomen, velum, and asymmetrical deficits in the jaw, lips, and tongue (Dysarthria), and a severe motor planning disorder (Apraxia.) Matt is non-verbal and is unable to coordinate oral airflow with vocalizations. He communicates in complete sentences with appropriate context and use of humor and sarcasm.” !
Rehabilitative Feeding and Speech Techniques for Teens and Adults
What Is Oral Placement Therapy?
TY
SPEECH C LA RI
TONGUE ABDOMEN
TY
CHEEKS LIPS
VELUM
“Rehabilitative Feeding and Speech Techniques for Teens and Adults
Published Article
Bahr, D., & Rosenfeld-Johnson, S. (May, 2010). ! Treatment of children with speech oral placement disorders ( OPDs ): A paradigm emerges. ! Communication Disorders Quarterly, 31 (3), 131-138.!
JAW
SPEEC H C LA RI !
Rehabilitative Feeding and Speech Techniques for Teens and Adults
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
1
The Tactile System 1. Tactile Hyposensitivity: An under-response to tactile input.! !
2. Tactile Hypersensitivity: An over-response to tactile input.! !
3. Mixed Sensitivity: Any combination of hyper, hypo or normal sensitivity.! !
4. Fluctuating Tactile Sensitivity: Responses that change over time.! _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _!
•
!
Tactile Defensiveness: A learned tendency to respond negatively or emotionally to tactile input.
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Assessing the Oral Sensory System ALWAYS: ! 1. Start from the outside and work your way in! 2. Be systematic! 3. Begin with the least input if unsure! ! ! ! !
ASSESSMENT: ! 1. Knees, Hands, Shoulders, Cheeks, Lips! 2. Oral Cavity - Lips, Buccal Cavity, Upper and Lower Gum Ridges, Blade of Tongue, Lateral Margins of Tongue, Gag Reflex? Palate
!
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Oral Placement Therapy for
Speech Clarity and Feeding
x
x
x x x
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
1. To increase the awareness of the oral mechanism! 2. To normalize oral tactile sensitivity! 3. To improve the precision of volitional movements of oral structures for speech production ! 4. To increase differentiation of oral movements! a. dissociation: The separation of movement, based on stability and adequate strength, in one or more muscle groups.! b. grading: The controlled segmentation of movement through space based upon dissociation.!
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Oral Placement Therapy for
Speech Clarity and Feeding 1. To increase the awareness of the oral mechanism! 2. To normalize oral tactile sensitivity! 3. To improve the precision of volitional movements of oral structures for speech production ! 4. To increase differentiation of oral movements! a. dissociation: The separation of movement, based on stability and adequate strength, in one or more muscle groups.! b. grading: The controlled segmentation of movement through space based upon dissociation.! c. fixing: An abnormal posture used to compensate for reduced stability which inhibits mobility.! 5. To improve feeding skills and nutritional intake! 6. To improve speech sound production to maximize intelligibility Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
2
Normal Speech Clarity
Dysarthria
1. Functional Movement Intact: YES! ! Mobility, Agility, Precision, Stability, Endurance, Dissociation, Grading! 2. Motor Planning Intact:
YES
Speech! !
Clarity! !
WNL
Speech! !
Sound! !
Disorder: Dysarthria
Foundation: Adequate
1. Functional Movement Intact: NO! 2. Motor Planning Intact:
YES! Oral-Placement & Articulation Therapies
Foundation: Insufficient
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Apraxia with Dysarthria Component
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
1
HIGH MEDIUM LOW
2 3 1. Functional Movement Intact:
NO! 2. Motor Planning Intact:
NO! Oral-Placement & Motor Speech Therapies
Apraxia and Dysarthria Component
Foundation: Insufficient Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
4 5 6 7 8
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Dissociation: LIPS FROM JAW PHONEME EX.
MUSCLE MOVEMENT !
Following normal speech development
! ! 1. Open! !! Closed to Open ! ! ! !! Open to Closed! ! 2. !Protrude! !! Retract! ! ! 3. !Lower Lip Retraction/Tension! !! Lower Lip Protrusion/Tension!
!
! !
(ah, uh)! ! !
(m, p, b)! ! !
(oo, oh, w, ee, ih)! ! ! !
(f, v)! !
(sh, ch, j, r, er)
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Dissociation: TONGUE FROM JAW MUSCLE MOVEMENT
! 1. Retraction- Protrusion: Balance (Equal range of ! motion)! ! 2. Retraction- Protrusion: Imbalance! Gradual increase in retraction! Gradual decrease in protrusion! ! 3. Retraction (stability) - Lateralization of tip! !
!
a. Midline to both sides!
b. Across midline! ! 4. Retraction - Tip Elevation/Depression! ! 5. Retraction - Back of Tongue Side Spread!
PHONEME EX. ! ! !
! (all sounds except th)! ! ! ! ! ! ! ! ! (t, d, n, l, s, z, sh, ch, j, k, g)! ! (stability for co-articulation, er)
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
3
A Three-Part Treatment Plan for
Oral-Placement Therapy (OPT)
Speech
Feeding
Oral-Placement Therapies
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Task Specificity Speech for Speech
Acquired Functional Deficits in Down Syndrome
Once the foundational movements for speech are observed, we MUST transition that movement into function for feeding or speech. !
•
Inter-dental tongue posture!
•
Conductive hearing loss!
•
Upper respiratory problems!
•
Open mouth!
•
Mouth breathing!
•
Large tongue!
•
High, narrow palatal vault
! !
(Bahr, 2001, pp.3-4; Green, et al., 1997; Moore & Ruark, 1996; Ruark & Moore, 1997)! !
!
When the movement is transitioned into function, you will no longer need Oral Placement Therapy for that movement. !
! !
!
!
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Why is feeding so important to an Oral Placement Therapy program?
Tongue Thrust 1. Retraction- Protrusion: Balance (Equal range of motion) ! !
•
Gradual increase in protrusion!
•
Gradual decrease in retraction!
!
!
2. Retraction – Protrusion: Imbalance ! •
Significantly more protrusion than retraction for function: feeding and speech Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
The muscles used in feeding are the same muscles used in speech.! !
We need:! !
1. Lip closure or rounding on a spoon before it is removed.! !
2. Chewing solids on the back molars - masseter muscles.! !
3. Straw drinking with lip rounding and tongue! retraction - no biting. The straw should not touch the! tongue during drinking. Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
4
Why is feeding so important to an Oral Placement Therapy program?
STRAW DRINKING: Begin with a regular diameter straw to assess the skills. As the oral functioning improves, increase the resistance by increasing the complexity of the straw.!
SPOON FEEDING: !
• !
• !
•
Why is feeding so important to an Oral Placement Therapy program?
Lateral Placement!
!
Specific goals may be:!
Front Placement!
!
•
Spoon Slurp
• • • •
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Tongue Retraction and Grading! Lip Rounding! Defining Facial Musculature! Jaw Stability! Independent Self-Feeding
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Straw Hierarchy - Thin Liquids (8 Straws in Hierarchy)
Straw #1
GOALS: Lip Protrusion, Tongue Blade Retraction/Grading! Begin with either Straw #1 or #4!
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
!
Rehabilitative Feeding and Speech Techniques for Teens and Adults
Straw #1
!
Rehabilitative Feeding and Speech Techniques for Teens and Adults
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
5
Straw #8
1 2 3 4 5 6 7
8
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
8
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Back of tongue – side spread
DISSOCIATION: Tongue from Jaw MUSCLE MOVEMENT
! 1. Retraction- Protrusion: Balance (Equal range of ! motion)! ! 2. Retraction- Protrusion: Imbalance! Gradual increase in retraction! Gradual decrease in protrusion! ! 3. Retraction (stability) - Lateralization of tip! !
!
a. Midline to both sides!
b. Across midline! ! 4. Retraction - Tip Elevation/Depression! ! 5. Retraction - Back of Tongue Side Spread! Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
PHONEME EX. ! ! !
! (all sounds except th)! ! ! ! ! ! ! ! ! (t, d, n, l, s, z, sh, ch, j, k, g)! ! (stability for co-articulation, er)
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Activities to Improve Feeding Safety and Speech Clarity Abdominal Grading Activity: !
Tongue
!
Horn Blowing Hierarchy: Criteria for success = 25X in rapid succession without a break for each horn in the hierarchy!
Lips Jaw
Duration Requirements: Horn #1: any duration; #2: 1 second duration;! #3 & 4: 1+ second duration; #5, 6, 7 & 8: 2 second duration;! #9 & 10: 2+ second duration; #11 & 12: 3 second duration.! Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Rehabilitative Feeding and Speech Techniques for Teens and Adults
6
Resonation Activities Why do adults with the diagnosis of Down syndrome sound hyper-nasal? What is the velum and why it is !
1
important?!
3
Oral-Nasal Contrasts (hoo-m)
4
Refer to Oral Placement Therapy (OPT) for Speech Clarity and Feeding! ! (Rosenfeld-Johnson, S., 2001 Revised 2009)
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
HIGH MEDIUM LOW
2
5! 6 7 8
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Oral Placement Therapies
Jaw Grading Bite Blocks Three sequential exercises for each Bite Block height:!
JAW EXERCISES !
!
1. Bite-Tube Hierarchy:! Navy Blue Tube! Orange Tube! Purple Tube! Green Tube!
! !
1. Bite Block! !
2. Twin Bite Block! !
3. Bite Block for Jaw Stability
! !
2. Jaw Grading Bite Blocks! !
! Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Scenarios That Require Jaw Exercise Therapy
DISSOCIATION: Tongue from Jaw MUSCLE MOVEMENT
A. Symmetrical Jaw Instability: both sides are equally weak! ! !
B. Asymmetrical Jaw Instability: both sides are weak, but one! side is weaker! !
! 1. Retraction- Protrusion: Balance (Equal range of ! motion)! ! 2. Retraction- Protrusion: Imbalance! Gradual increase in retraction! Gradual decrease in protrusion! ! 3. Retraction (stability) - Lateralization of tip! !
!
C. Asymmetrical Jaw Instability: only one side is weak
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
!
a. Midline to both sides!
b. Across midline! ! 4. Retraction - Tip Elevation/Depression! ! 5. Retraction - Back of Tongue Side Spread!
PHONEME EX. ! ! !
! (all sounds except th)! ! ! ! ! ! ! ! ! (t, d, n, l, s, z, sh, ch, j, k, g)! ! (stability for co-articulation, er)
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
7
Oral Placement Therapy
Oral Placement Therapy BLADE RETRACTION ! Lip Protrusion=Tongue Retraction! ! Straw Drinking Hierarchy!
TONGUE TIP ELEVATION AND/OR DEPRESSION:
TalkTools® Tongue-Tip Elevation/Depression Tool ! Prerequisite: Complete all 3 exercises using Bite Blocks #2 - #7!
Tongue Lateralization: TalkTools® Tongue-Tip Lateralization Tool! Prerequisite: Complete all 3 exercises using Bite Block #2 - #5!
Tongue- Tip Elevation Up! ! Tongue- Tip Depression Down! ! Up and Down!
!
!
!
Midline to Left! ! Midline to Right! ! Across Midline!
Criteria for success: Repeat the appropriate unit 5 times Position A
Position C
Position B
! ! !
Criteria for success: Repeat the appropriate unit 5 times! Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Clint: Case Study 27 years old Reason for referral: Adult male with a large gap between what he says and what the listener can understand! !
History of Speech-Language Therapy: Ages 2 through 21 through EI and the local public school system where the primary focus was language development and language usage! !
What to look for in this video concerning speech clarity: ! !
Articulation: omits many final sounds poor jaw grading! blade for tip alveolar sounds poor tongue grading! hyper-nasality poor velar grading!
!
Breath Control: dysfluencies
poor abdominal grading
Clint: Case Study - 3 sessions per week for 1 month CHANGES: ! Articulation: Using many final speech sounds! ! Pre-Test Jaw Grading: Post-Test Jaw Grading:! Bite Block #2 - 13 seconds Bite Block #7 - 15 seconds! Bite-Tube Hierarchy: ! Purple: 4(L) -10(R) - 4(L) Purple: 10(L) -10(R) ! Green: None Green: 10(L) -10(R) ! Slow Feed: ! Back Molars: 4 consecutive Back Molars: 9 consecutive! !
Pre-Test Tongue Retraction: Straw: #3 - 3/8” Spoon Slurp: 17
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Post-Test Tongue Retraction:! Straw: #3 - 3/8” ! Spoon Slurp: 25 ! Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
Clint: Case Study CHANGES: ! Breath Control: more fluent ! ! Pre-Test Abdominal Grading: Post-Test Abdominal Grading:! Horn Hierarchy: #6, 7 reps. Horn Hierarchy: #6, 17 reps.! !
Sara Rosenfeld-Johnson MS, CCC-SLP ! ! !
!
CHANGES: ! Hypernasality: no change! ! Pre-Test Velar Grading: Pre-requisite: Horn #9
TalkTools
Pre-Test Velar Grading: Pre-requisite: Horn #9
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
!
2209 Mechanic Street Charleston, SC 29405 Email:
[email protected] www.talktools.com
Rehabilitative Feeding and Speech Techniques for Teens and Adults… It is not too late!I
8
