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Sara Rosenfeld-Johnson’s Approach to
Oral-Motor Feeding and SpeechTherapy
What is oral-motor therapy and what is unique about SRJ oral-motor therapy?
Oral-motor therapy addresses the physical movements of speech and feeding. Sara Rosenfeld-Johnson’s approach to oral-motor therapy (TalkTools TherapyTM) evolved from a need to address the ways specific speech sounds are produced and the role of feeding techniques in overall oral-motor development.
TalkTools TherapyTM incorporates the proprioceptive and kinesthetic feedback necessary to address the sensory aspects of speech production and feeding skills; we call this the “feel of speech.” Auditory and visual models of feedback and cueing often do not provide adequate input for those who demonstrate difficulty knowing how to produce specific sounds and combine sounds in connected speech. The therapies and tools used in TalkTools TherapyTM provide tactile cueing, or the feel of speech, to promote more appropriate movement patterns for standard speech production and clarity as well as appropriate feeding.
Accepted definitions of oral-motor therapy include Hammer’s (2007) definition, “having to do with movements and placements of the oral structures such as the tongue, lips, palate, and teeth,” and Marshalla’s (2004) definition, “the process of facilitating improved oral (jaw, lips, tongue) movements.” The American Speech-Language-Hearing Association’s (ASHA) National Center for Evidence-Based Practice in Communication Disorders (2007) presented the results of an ad hoc committee on the efficacy of oralmotor exercises. The committee defined oral-motor exercises as “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” (as cited in Mosheim & Banotai, 2007). Combined, these definitions provide a basic physiological context for speech sound production and other skills involving the oral structures.
TalkTools TherapyTM is appropriate for anyone displaying reduced mobility, agility, precision, and endurance of the oral structures and musculature that adversely affect speech production, feeding, and oral management as compared to typically developing peers. It is also appropriate for clients with dysarthria, affecting oral-motor movement for speech and feeding.
In addition to the feel of speech, only speech-like movements are targeted in TalkTools® oral-motor therapy. Movements that do not imitate speech should not be used, as they are ineffective in the remediation of speech sound errors. This philosophy is in agreement with those opposed to the use of oral-motor therapy for the improvement of speech articulation:
– “there is no relevance to the end product of speaking by using an exercise
of tongue wagging, because there are no speech sounds that require tongue wagging” (Lof, G. L.,
2003);
– “The goal of speech therapy is NOT to produce a tongue wag, to have strong articulators, to puff out
the cheeks, etc. Rather, the goal is to produce intelligible speech” (Lof, G. L., 2006);
– “no speech sound requires the tongue tip 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. Oral
movements that are irrelevant to speech movements will not be effective as speech therapy
techniques”(Lof, G. L., 2006).
The goals of oral-motor, feeding, and speech therapy are to increase the awareness of the oral mechanism and normalize oral tactile sensitivity (Fisher, 1991, Schmidt, 1988 in Bahr, 2001; Morris & Klein, 2000), improve the precision of volitional movements of oral structures for speech production (Dewey, 1993; Newmeyer, Grether, S., Grasha, C., White, J., Akers, R., Aylward, C., Ishikawa, K., & deGrauw, 2007; Robin, D. A., 1992), increase differentiation of oral movements (Gooze, Murdoch, Ozanne, Cheng, Hill, Gibbon, 2007; Green, Moore, Reilly, Higashikawa, & Steeve, 2000; Morris & Klein, 2000; Rosenfeld-Johnson, 2001), improve feeding skills and nutritional intake, and improve speech sound production to maximize intelligibility. In TalkTools TherapyTM, three main concepts and movements of the jaw, lips, and tongue are incorporated into each activity:
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.
These three concepts are consistent with the goals above in that they encompass the oral movements necessary for adequate speech and feeding skills. Each exercise and therapy activity promoted by TalkTools TherapyTM integrates the concepts of dissociation, grading, and fixing to better understand, assess, and treat oral-motor speech and feeding disorders.
TalkTools TherapyTM incorporates concepts of normal, age-appropriate motor development to determine appropriate therapy for each child. For example, studies indicate that jaw control is established by about 15 months, before control is established for the upper and lower lips (Green, Moore, Reilly, Higashikawa, & Steeve, 2000; Green, Moore, & Reilly, 2002). This indicates that the jaw is the basis for motor speech development. Therefore, the jaw is an important component of the speech and feeding skills assessed and treated in each session according to each child’s needs. Stability (in the jaw and body) for speech and feeding is addressed before more complex motor skills such as lip and tongue dissociation or later-developing speech sounds. This ensures every child has the motor skills necessary to accomplish age-appropriate speech and feeding goals.
TalkTools TherapyTM is used in conjunction with other speech therapies and does not replace the need for direct work on speech production. A common misconception of oral-motor therapy is it is used in isolation; however, TalkTools TherapyTM was developed to be used in conjunction with other speech, language, and feeding interventions. Oral-motor therapies improve the foundational skills necessary to achieve appropriate oral-motor skills, speech sound acquisition, feeding skills, and oral management. To be effective, they should be used in combination with speech, language, and feeding interventions for effective remediation of speech sound errors and speech clarity or the treatment of feeding disorders.
Once the foundational movements for speech are observed by the clinician and achieved by the client, those movements are immediately transitioned into function for feeding and speech (Bahr, 2001, pp.3-4; Green, et al., 1997; Moore & Ruark, 1996; Ruark & Moore, 1997). When movement is transitioned into function, oral-motor therapy is no longer necessary for that movement.
SRJ TherapyTM and Innovative Therapists International, Inc. are working hard to provide easy access to education, therapeutic intervention, therapy materials, and research and development within the framework of Evidence-Based Practice. We have joined the effort to engage in evidence-based practices and research efforts to validate the use of TalkTools TherapyTM. Our unique methods of oral-motor therapy have proven effective for clients with oral-motor deficits in therapeutic settings and we are excited to
begin clinical trials to validate those results. We are working with researchers to provide practitioners and families with evidence-based therapeutic methods to address the oralmotor aspects of speech, sensory and feeding deficits. Several research projects are underway addressing various aspects of TalkTools TherapyTM techniques, tools and methodologies. Our research findings will be made available to others so they may be subjected to peer review. We are also collaborating with other professionals to expand our knowledge of oral-motor applications for sensory, feeding and speech development.
Our goal at Innovative Therapists International, Inc. is to provide today’s
therapists with new and innovative techniques that can, when combined with existing client skills, help each child achieve maximum success with adequate oral-motor skills for speech and feeding.
什麼是口部肌肉治療? SRJ的口肌治療法有什麼獨特之處？
口部肌肉治療是針對說話和餵食的物理運動。 莎拉蘿森菲德-莊臣的口部肌肉療法 (TalkTools TherapyTM) 從發音說話/ 製造聲音的方法, 以及餵食技巧在整體口部肌肉發展的角色中建立出來。
TalkTools TherapyTM論及發音講話和餵食的技巧所需的本體感受和肌肉感覺的回饋; 我們稱此為「講話的感覺」。 對於那些在製造聲音和在語句中結合聲音有困難的人士, 聽覺和視覺模式的提示往往未能提供充分的輸入。 TalkTools TherapyTM所使用的口肌工具和療法提供觸覺提示, 或講話的感覺，促進更加適當的標準發音講話模式, 說話清晰度和餵食技巧。
現今被接受的口部肌肉療法理論包括Hammer(2007)的定義， 「必須處理口腔結構的運動和位置, 例如舌頭、嘴唇、上顎和牙齒」; 以及Marshalla(2004)的定義， 「促進改善口部(下顎、嘴唇，舌頭)運動的過程」。 美國言語, 語言及聽力協會的(ASHA)的國家溝通障礙驗證實踐中心(2007), 在口部肌肉訓練果效的研究上提出了一個專門委員會的結果。 這個委員會定義了口部肌肉訓練作為「介入知覺刺激, 意欲影響口腔咽顎機制的生理學基礎, 因而改進它的功能, 包括嘴唇、下顎、舌頭、軟顎、喉部和呼吸肌肉的活動 (引於Mosheim & Banotai, 2007)。 總扣來說，這些定義為發音講話及其他口腔結構的技巧提供生理學上的論據。
TalkTools TherapyTM適用於任何因口腔結構或肌肉組織薄弱的患者, 包括薄弱的活動性、敏捷性、精確度和耐力等而導致發音講話, 餵食技巧和口腔處理落後於典型發展同伴的人士。 這套治療亦適用於中樞性構音障礙的患者。
除講話的感覺之外，TalkTools®口肌治療的目標只瞄準於與發音有關的活動。 與發音講話無關的口部肌肉運動不應該被使用，因為他們對於語音和誤音治療亳無幫助。我的這些哲學與那些反對運用口部肌肉療法以改善說話清晰度的學者的意見其實是一致的：
- 「舌頭搖擺的練習與說話並不相關, 因為沒有一個語音是需要舌頭搖擺的。」 (Lof，G. L. 2003);
- 「語言治療的目標不是要做出舌頭搖擺， 強健的構音器官，面頰鼓漲等。 相反，目標應該是製造清晰可理解的說話。」 (Lof，G. L. 2006);
- 「沒有一個語音要求舌尖觸碰到鼻子; 沒有一個語音是要鼓漲面頰而製造 出來的; 沒有一個語音是跟吹氣時一樣製造出來的。跟講話時的活動毫不相關的口部運動不會是有效的語言治療技巧。」(Lof，G. L. 2006)。
口部肌肉，餵食和言語治療的目標是增加口腔機制的認知, 將口腔觸覺的敏感度正常化 (Fisher, 1991; Schmidt, 1988; Bahr，2001; Morris & Klein, 2000)，改進發音說話時口腔結構的自主運動的精確度 (Dewey, 1993; Newmeyer, Grether, S., Grasha. C., White, J., Akers, R., Aylward, C., Ishikawa, K., & deGrauw 2007; Robin，D.A., 1992)，增加口部活動的分化 (Gooze， Murdoch， Ozanne，Cheung，Hill，Gibbon, 2007; Green, Moore, Reilly, Higashikawa, & Steeve, 2000; Morris & Klein, 2000; Rosenfeld-Johnson, 2001)，改進餵食技巧和營養吸取，并且改善發音說話, 達致最佳的清晰度/可理解性。在TalkTools TherapyTM中， 下顎、嘴唇和舌頭的三主要概念和運動會被合併到每個活動裡：
a. 分化/ 分開獨立活動力 (Dissociation)：在一個或更多的肌肉組織, 基於穩定和足夠的力量，而作出活動上的分離;
b. 分級調控力 (Grading)： 在分開活動之後, 肌肉於空間作自控的分段活動;
c. 緊繃 (Fixing)： 一個不正常姿勢, 用以補嘗減弱了的穩定性, 這個姿勢會阻礙肌肉的活動力。
這三個概念與上面的目標是一致的, 因為他們包含了講話和餵食時所需的口部肌肉活動。 TalkTools TherapyTM提倡的進的每一個練習和療法也統合了分化， 分級調控力和緊繃的概念, 以更有效的理解, 評估和治療口肌, 說話及餵食障礙。
TalkTools TherapyTM是與其他言語治療方案一同使用的, 它並不是用來代替直接的言語表達訓練。 很多時人們都會有一個誤解, 以為口部肌肉治療是一套獨立的訓練。 可是， TalkTools TherapyTM是要與其他言語, 語言和餵食訓練一同進行的。 口部肌肉治療改善適當口肌技巧, 語音獲得, 餵食技巧和口腔管理所需的基礎技巧。 要收到果效, 便應與其他的言語, 語言和餵食治療一同進行, 以有效的改善誤音, 說話清晰度和治療餵食技巧。
一旦治療師在臨床觀察中發現受訓者達到了說話的基礎活動， 那些活動便應立刻被過渡至餵食和講話的功能上 (Bahr, 2001， pp.3-4; Green，et al.，1997; Moore & Ruark, 1996; Ruark & Moore, 1997)。 當活動被類化到功能之後，這個活動上的口部肌肉練習便不再是必要的了。
SRJ TherapyTM和Innovative Therapists International，Inc. (創新治療師國際中心) 一直都艱苦工作, 提供對教育、 治療干預、 療法、 訓練工具和研究與開發的驗証實踐。 我們努力參與TalkTools TherapyTM的驗証實踐和研究。 我們獨特的口部肌肉治療方法被臨床證實能有效治療患有口部肌肉障礙的受訓者, 我們也興奮的展開臨床試驗, 以驗證這些結果。 我們正與一些研究人員一起工作, 為業界和家庭提供言語, 感知和餵食障礙中能被驗証實踐的治療方案。 現正有幾個研究計劃是針對TalkTools TherapyTM的技術、工具和方法而在進行當中。 我們的研究結果將會被公開， 以作同業的評審。 我們亦正和其他專業合作, 擴展於感知，餵食和語言發展上口部肌肉治療的知識。
我們創新治療師國際中心的目標在於為當代治療師提供最新及最具創意的技巧， 與其本身的治療技巧結合, 幫助每個孩子說話和餵食上達致最大的成功。
香港思進言語治療中心 言語治療師/ ITI TalkTools® 認可口部肌肉治療師王春燕 譯 2009年6月
版權所有© 不得翻印TalkTools®/ Innovative Therapists International
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香港思進言語治療
語言訓練
