Appendix 26(B) - Oromotor exercises – MDT (multidisciplinary) approach

Leaflet for parents

What are oromotor exercises?

Oromotor exercises are things like encouraging blowing, sucking, holding lollipop sticks between lips to gain lip closure, encouraging tongue movements to reduce protrusion, stroking of the cheek, breastfeeding, and many more.  It is a big commitment from parents and little guidance out there that is free for all, and to pay for the "therapist/therapy/resources/courses" is incredibly expensive (hundreds of pounds) and not at all available for the majority of our parents (but it is available to search for "Talk Tools" so parents ask us about it).
We do not also have a clear policy on what we can and cannot show parents and advise, especially with the lack of real evidence based research. It's also costly in terms of time and training. 

Research - pros and cons

Fundamentally, there is no overall evidence-based research that shows improved communication/speech with oromotor exercises.  However, there are some arguments for benefits of oromotor exercises - and this is around the actual anatomy of the jaw/palate/tongue/chewing muscles.  In other European countries, like Spain, our specialist dentist mentioned there is a dental/feeding/SLT combined approach to show parents these oromotor exercises and continue this from newborn onwards.  In her experience, and research she has looked into, there is evidence for some improvements in jaw and palate formation, and probably also reduction in tongue protrusion and improvements in mastication, leading to a change (even if subtle) is some of the underdeveloped mid-face that the children have (breastfeeding also has a positive effect on these changes too).  This potentially leads to fewer dental complications in the future (which is a common problem in DS) and less risk of sleep apnoea because of the change in palate shape/mid-face.

Oromotor exercises on anatomy/dental effects

Using an evidence-based approach, the current evidence highlights the contraindications to using non-functional oromotor activities to improve speech and feeding.  However, following an oro-motor subgroup of relevant professionals being developed, we are looking into the different options, research and advice.  It needs to be evidence based and also discussed individually with parents as it is not a “one-approach” fits all.  The paediatric specialist dentist, preschool support team and community paediatrician as well as the dysphagia team plan to produce some parental leaflets and exercises, which can be given to some families (as decided by the community paediatrician) where it may be helpful.   There is evidence to suggest these exercises could help with jaw/facial changes in anatomy which could have an improved impact on eg sleep apnoea or teeth development (also clear evidence for breastfeeding helping with this).  This is a different outcome to improving speech or chewing/mastication and needs proper training and understanding by parents and professionals.

Oromotor exercises and oral desensitisation

On the issue of desensitising and oro-motor aversion – these exercises again are definitely not evidence-based therapy for this.  They potentially could help but could also potentially worsen things, if done in the wrong way.  Could the oromotor exercises and equipment techniques used be somehow useful in “Desensitising" some of the children to something in their mouth which helps eg with dental care or on the other hand, could these exercises and equipment actually cause further dental/food aversion?    Currently, Barnet paediatric dysphagia team have a clear position here:  Oro-desensitisation programmes can be helpful for tolerance of teeth cleaning e.g. neonates/ children with PEGs and to reduce the impact of negative oral experiences during/after a period of invasive medical interventions. This is done through messy play as children need to desensitise through their other senses of touch/sight /smell, oral acceptance of new foods is the final step to eating.  The Dentist needs to work with the Dysphagia team of Speech and language therapists (see Appendix 3).

Further research, reading, courses, books

Articles and research

The effect of oro-motor exercise (ORE) on swallowing in children: an evidence-based systematic review.  Arvedson et al, Developmental medicine and child neurology, May 2010.  “There is insufficient evidence to determine the effects of ORE on children with sensorimotor deficits and swallowing problems.”

Managing eating and drinking difficulties (dysphagia) with children who have learning disabilities: What is effective? Authors are Celia Harding and Helen Cockerill. Clinical Child Psychology and Psychiatry 20(3) · Jan 2014. People who work with children who have neurological and learning disabilities frequently need to manage the health and emotional risks associated with eating, drinking and swallowing (dysphagia). Some approaches can support children to develop oral feeding competence or to maximise their ability to maintain some oral intake supplemented with tube feeding. However, some clinicians feel that oral-motor exercises can support eating and drinking skills as well as speech and language development, whereas there is little evidence to support this.  The implied "beneficial" association between oral-motor exercises, speech and swallowing skills gives a false impression in terms of future outcomes for parents and carers of children with learning disabilities. This paper considers oral-motor approaches in the remediation of dysphagia and the need for a cultural shift away from this view.   Realistic and useful outcomes for people with learning disabilities need to be an essential part of therapeutic intervention.

Myofunctional therapy and prefabricated functional appliances: an overview of the history and evidence.   Wishney, Morgan; Darendeliler, M Ali; Dalci, Oyku.  Australian dental journal; Mar 2019.  “Malocclusion represents the clinically observable endpoint of numerous genetic and environmental influences. Oral Myofunctional Therapy (OMT) aims to treat malocclusions by improving the oral environment through re-education of musculature and respiratory patterns. However, a more recent application of OMT for the treatment of OSA suggests some benefits although more research is needed to clarify this effect.” 

Effects of an oral-pharyngeal motor training programme on children with obstructive sleep apnea syndrome in Hong Kong: A retrospective pilot study.   Cheng S.Y.; Kwong S.H.W.; Pang W.M.; Wan L.Y.  Hong Kong Journal of Occupational Therapy; Dec 2017; vol. 30; p. 1-5Dec 2017.  “The findings of this study support the role of occupational therapist in oromotor training modalities to improve the respiratory function for children with OSA in Hong Kong.” 

  

Summary of Oromotor subgroup meetings and outcome (2019): 

Attended by: SLTs- Dysphagia team (hospital and community-based), Community Paediatricians, SLT- communication, Health visiting, Breastfeeding coordinator, Paediatric senior Dentist, Early Years SEND DS advisor.

Background: This was set up to try and get more of a consensus of oromotor function and exercises as there are different opinions, research is available but sometimes scanty, there are different levels of skill and different perspectives but our parents are asking about it and we need to find some common ground which we ALL adhere too and not confuse parents further. 

Summary: So from a medical and dental perspective, there is a reasonable argument to propose we teach/encourage parents to do these regular oromotor exercises (with auditing)- BUT we cannot say this improves speech and communication skills or oro-desensitisation.  The research is scanty and not specific enough, in our group of children, so Barnet could be the pioneers, in fact, even discussing this puts Barnet ahead of the game in this field.  

Take home messages and future plans:

  1. Breastfeeding has clear benefits with these anatomical changes mentioned above eg jaw development, with oro-desensitisation, with less risk of lung damage from aspiration (as a result of issues with the baby’s swallow.  All professionals need to encourage breastfeeding in our families and arm them with information and practical support, without judgement nor pressure. But we must try, as it is sometimes easier to assume a baby with Down Syndrome won’t be able to breastfeed or we ourselves don’t know if they can - so seek advice/training and seek out others who can help.

  2. Dental and Early Years SEND DS advisory teams to develop a simple pamphlet/leaflet for parents to have, using bits of equipment that is available to all and does not need to be brought from any particular website. eg bubbles, lollipop or tongue depressor sticks, straws.  Some exercises require no equipment eg using your hand to stroke the cheeks or your finger to encourage sensation within the mouth and cheeks.

  3. Training opportunities and developments.

  4. Communication with parents: We need to be absolutely clear we are not forcing or suggesting parents are wrong for not doing these exercises, as with all therapies.  We also need to be very careful we explain to individual parents what the leaflets mean and reason behind them with the commitment involved, and maybe it is not for every family for various reasons and so each member of the subgroup, in particular the lead paediatrician, needs to really think about this aspect at every contact with the family.  Paediatrician's role here: It will need some paediatric approval to go ahead and suggest parents to try these, at least to start with.  This is to ensure we are clear with parents about the issues raised above, the research and evidence and the objectives and it is consistent.  What we want to avoid is eg a parent who perhaps misunderstood this and who could potentially be too over-vigorous with the exercises causing more damage than good in the longer term.  This requires professionals to ensure we have tried our very best to communicate all of this clearly and documented it.  This is going to be the lead paediatrician’s role for the foreseeable future. Once the leaflets are developed by members of the sub-group, the role can be re-evaluated and audited, to see if it can be expanded appropriately to other professionals.  Please, if questions, discuss with professionals who care for your child.  

  5. There may be an opportunity to do some of these exercises in the BIG-DS hub at Underhill children’s centre, therefore with supervision and support, perhaps an age-appropriate communal snack time, but this is a longer-term project involving more time, training, equipment and storage etc.

What else is out there?

Talk Tools:  TalkTools

This is not supported by the NHS and our therapists, the evidence is incomplete at present. There are ongoing discussions and more research into this area and in Barnet we have set up an oromotor subgroup to examine this area further.  Talktools is an expensive program that is private and many parents ask about it so here are the links, but to reiterate we are not promoting it. There may be some evidence for some use for improving dentition, mastication (chewing), tongue protrusion and palate shape and our specialist paediatric dentist is involved with us to promote these positive outcomes.

Talk Tools promote Oral Placement Therapy (OPT) which uses a hierarchical based approach to improve speech clarity and feeding skills in individuals of all ages and across diagnoses. The techniques focus on motor movement activities to improve phonation, resonation, and speech clarity.   OPT is combined with a tactile-sensory approach to aid a variety of speech and feeding issues. OPT involves the use of therapy tools to train and transition muscle movements for speech production.   Oral Placement Therapy is a speech therapy which utilizes a combination of: (1) auditory stimulation, (2) visual stimulation and (3) tactile stimulation to the mouth to improve speech clarity.  Talk Tools explain that OPT is only a small part of a comprehensive speech and language program and should not be done in isolation. The activities are carefully selected to stimulate the same movements used in the targeted speech production. They can be completed in under 15 minutes and can be used to refocus attention and concentration from a sensory processing perspective.