Evidence-Based Systematic Review: Effects of Nonspeech ...€¦ · Evidence-Based Systematic...

Evidence-Based Systematic Review:Effects of Nonspeech Oral MotorExercises on Speech

Rebecca J. McCauleyThe Ohio State University, Columbus

Edythe StrandMayo Clinic and Mayo College of Medicine, Rochester, MN

Gregory L. LofMGH Institute of Health Professions, Boston

Tracy SchoolingTobi FrymarkAmerican Speech-Language-Hearing Association, Rockville, MD

Purpose: The purpose of this systematic re-view was to examine the current evidence for theuse of oral motor exercises (OMEs) on speech(i.e., speech physiology, speech production, andfunctional speech outcomes) as a means of sup-porting further research and clinicians’ use ofevidence-based practice.Method: The peer-reviewed literature from 1960to 2007 was searched for articles examining theuse of OMEs to affect speech physiology, pro-duction, or functional outcomes (i.e., intelligibility).Articles that met selection criteria were appraisedby 2 reviewers and vetted by a 3rd for methodo-logical quality, then characterized as efficacy orexploratory studies.Results: Fifteen studies met inclusion criteria;of these, 8 included data relevant to the effects of

OMEs on speech physiology, 8 on speech pro-duction, and 8 on functional speech outcomes.Considerable variation was noted in the partici-pants, interventions, and treatment schedules.The critical appraisals identified significantweaknesses in almost all studies.Conclusions: Insufficient evidence to supportor refute the use of OMEs to produce effectson speech was found in the research literature.Discussion is largely confined to a considerationof the need for more well-designed studies usingwell-described participant groups and alterna-tive bases for evidence-based practice.

Key Words: oral motor treatment,evidence-based systematic review,speech disorders

In 2005, the American Speech-Language-Hearing Asso-ciation’s (ASHA’s) National Center for Evidence-BasedPractice in Communication Disorders (N-CEP) initiated

a number of evidence-based systematic reviews (EBSRs)in the area of communication sciences and disorders. Topicswere selected based on their perceived importance and use-fulness to speech-language pathologists (SLPs) and audiolo-gists through a Knowledge-Attitudes-Practices Survey (Mullen,2005). As part of that survey, ASHA members were asked toidentify specific clinical areas about which they wanted moreevidence or a better understanding of the current evidence.Results from that survey revealed oralmotor exercises (OMEs)

as one of the most frequently identified topics of interest forSLPs.

Recent surveys of practicing SLPs in the United States,Canada, and Great Britain (Hodge, Salonka, & Kollias,2005; Joffe & Pring, 2008; Lof & Watson, 2008) suggestthat OMEs are widely used. In fact, a considerable majorityof survey respondents (>70% in each of these three sur-veys) reported that they made use of them in their practice.Rationales shared by SLPs in the two North Americansurveys included the achievement of improved speechproduction, increased awareness of the articulators, andstrengthening.

Research

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Despite the popularity of OMEs, however, their probablevalue has been seriously questioned (e.g., Lof & Watson,2008). Criticisms have typically cited a lack of supportiveevidence and problems with identified rationales (Clark, inpress; Forrest, 2002). In particular, rationales have beenquestioned in terms of their relevance for a particular pop-ulation (e.g., the use of strengthening exercises if strength isnot an underlying problem) and the likelihood that methodsused to implement them will be effective (e.g., the use ofstrengthening exercises that seem unlikely to tax, and there-fore to strengthen, targeted muscles). Nonetheless, a numberof critics also suggest that given their widespread use andthe potential value of selected OMEs for specific purposes,vigorous investigation of OMEs is warranted.

Because of the absence of systematic reviews on theeffectiveness of OMEs (at the conception of this series),the documented interest by clinicians in OMEs (Mullen,2005), and controversies about their use with a variety ofpopulations (e.g., Hodge et al., 2005; Lof & Watson, 2008),a systematic review on this topic was considered timely. Sys-tematic reviews are one of the highest forms of evidence foranswering clinical questions (Dollaghan, 2007; McCauley& Hargrove, 2004). EBSRs represent an emerging researchmethodology designed to reduce bias and promote transpar-ency in the synthesis of evidence for research and clinicalpurposes (Guyatt & Rennie, 2002), such as is needed forOMEs. As part of EBSR methodology, multiple reviewersfollow thoroughly prescribed procedures that include op-erationally defined criteria and the examination of inter-reviewer agreement to identify and assess the scientificliterature; their results offer the current best available evi-dence on a particular intervention or diagnostic procedureunder investigation.

Systematic reviews free individual clinicians and research-ers from finding, evaluating, summarizing, and synthesizingresearch articles spanning numerous years and journals. Further,such reviews reduce the likelihood that these same individ-uals will need to contend with the inconsistencies and proba-ble errors resulting from the informal and usually undocumentedprocess typifying most narrative reviews (McCauley &Hargrove, 2004). Thus, while no more immune from criti-cism than any other research method (Ylvisaker et al., 2002),EBSRs offer clear-cut bases on which proponents can de-fend (and critics attack) their conclusions. Depending on thematurity of research in a clinical area, EBSRs can serve asa starting point for clinicians and researchers who are inter-ested in obtaining a thorough, if imperfect, sense of (a) whatresearch has been done to support decision making in agiven area of clinical practice, (b) how rigorous that re-search has been, and (c) what further research needs to beconducted.

The purpose of this review was to examine the currentstate of evidence for the use of OMEs in speech treatment.OMEs were operationally defined as nonspeech activitiesthat involve sensory stimulation to or actions of the lips, jaw,tongue, soft palate, larynx, and respiratory muscles that areintended to influence the physiological underpinnings of theoropharyngeal mechanism to improve its functions. They mayinclude activities described as active muscle exercise, musclestretching, passive exercise, or sensory stimulation. This EBSR

is part of a series of reviews investigating the use ofOMEs acrossall aspects of SLP treatment (i.e., speech and swallowing).This article focused solely on the impact of OMEs on speech;in particular, it focused on three clinical questions concerningoutcomes commonly addressed in clinical practice:

1. What is the influence of OMEs on speech physiology(e.g., acoustic, kinematic, and articulatory placement)?

2. What is the influence of OMEs on speech production(i.e., perceptual accuracy)?

3. What is the influence of OMEs on functional speechoutcomes, where functional speech outcomes were mea-sures addressing the impact of the speech productionerrors on communication (i.e., intelligibility)?

For an EBSR examining the use of OMEs (specificallyneuromuscular electrical stimulation) on swallowing, seeClark, Lazarus, Arvedson, Schooling, and Frymark (2009).

MethodA systematic search of the literature was conducted start-

ing in December 2006 and continuing through September2007. Studies were initially considered for the review if theywere published in a peer-reviewed journal from 1960 to2007, were written in English, and contained original dataaddressing one or more of the clinical questions includedin this series of EBSRs. Studies that included surgical,medical, or pharmacological treatment or studies using liquidor food as part of the intervention were excluded. Addition-ally, studies that incorporated mixed treatments that werenot controlled for within the research design (e.g., studiesexamining speech treatment paired with oral motor treatmentwithout a speech treatment–only control group) were ex-cluded because they did not allow for an examination of theinfluence of OME. Twenty-one electronic databases andother sources were searched using a total of 71 expandedkey words related to OMEs, swallowing, and speech ther-apy. The following electronic databases were searched:Academic Search Premier, CINAHL, Communication &Mass Media Complete, EMBASE, ERIC, Evidence-BasedMedicine Guidelines, Health Source: Nursing, HighWirePress, National Electronic Library for Health, PsycArticles,PsycINFO, PubMed, REHABDATA, Science Citation Index,ScienceDirect, Social Science Citation Index, SUMSearch,TRIP Database, and the Cochrane Database of SystematicReviews. An electronic search of the ASHA journals and ofGoogle Scholar as well as a manual search of references fromall relevant articles were also completed.

As displayed in Figure 1, a total of 899 citations wereidentified as part of the broader search examining OMEsin speech and swallowing treatment. Two N-CEP reviewers(the fourth and fifth authors), blinded from one another’sresults, reviewed each abstract and initially identified 346citations as preliminarily meeting the inclusion criteria with91% agreement. Of those, 250 were subsequently excludedby these two reviewers because they did not directly ad-dress one or more of the larger set of clinical questions orreport original data. A total of 96 studies were identifiedfor inclusion in this series of EBSRs. Of these, 15 studies

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addressed one or more of the three clinical questions relatedspecifically to speech for final inclusion in this review.

The fourth and fifth authors, still blinded to one another’sresults, assessed the 15 studies for methodological qualityin the following areas: study design, assessor blinding,sampling/allocation, subject comparability/description, out-comes, significance, precision, and intention-to-treat (whenapplicable; Dollaghan, 2007). Each study received a pointfor each marker meeting the highest level of quality (seeTable 1), and a final score was derived from the total numberof indicators that met the highest level of quality. For studiesincorporating randomized controlled trials (i.e., studies inwhich participants were randomly assigned to a treatmentor control group), all eight quality indicators were relevant,leading to a maximum quality score of 8. For all other studydesigns, for which an intention-to-treat analysis was notapplicable, the highest quality score was 7. An intention-to-treat analysis of a randomized controlled trial ensures thatparticipants are analyzed according to the group to whichthey were initially randomly allocated, regardless of whetherthey dropped out, fully complied with the treatment, or crossedover and received the other treatment (ASHA, 2008). Suchanalyses are intended to help the study provide informationabout the quality of the decision to use a particular treatmentprior to any treatment having occurred—the same condi-tions under which such decisions are made clinically (Fletcher& Fletcher, 2005).

Each critical appraisal was reviewed and vetted by at leastone member of the three-member evidence panel (i.e., thefirst three authors) who also completed the data extraction(i.e., participant description, intervention provided, treatmentschedule, etc.) for the study. Agreement between the N-CEPand panel reviewers was greater than 98%, and any dis-crepancies in ratings were resolved via consensus amongthe full author panel. Along with assessing methodologicalrigor, each study was also characterized as efficacy or explor-atory research. To be considered efficacy research, a studyhad to incorporate an experimental or quasi-experimentaldesign, be conducted on a disordered population, and exam-ine the effects of OMEs as a treatment and not just a con-dition in which speech or swallowing skills were examined.The remaining studies not meeting those three criteria (i.e.,studies with nonexperimental designs, studies conductedon nondisordered populations, or studies using OMEs as acondition to examine speech or swallowing abilities insteadof as an intervention) were classified as exploratory research.A final synthesis of the body of scientific literature wasreported based on clinical question and corresponding re-search category.

For efficacy studies, detailed information regarding par-ticipants, treatment characteristics, and individual scores foreach quality indicator were given. For exploratory studies,a study summary and an overall quality score were reported.Effect sizes and confidence intervals were calculated for

FIGURE 1. Process for identification of included studies.

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outcome measures from efficacy studies whenever possible.Effect sizes are point estimates that indicate the importanceof a finding, rather than the likelihood that the observedeffect was due to chance or sampling error (which is themeaning of statistical significance). Confidence intervalsprovide an estimation of the precision of that point estimate.In other words, measures of effect size are designed to in-dicate the degree to which a null hypothesis is false, andthe corresponding confidence interval provides a range inwhich the true value of the effect size is most likely to oc-cur (Dollaghan, 2007). For group studies, Cohen’s d wascalculated from group means and standard deviations orestimated from results of analyses of variance or t tests.Although the magnitude of effect sizes was reported usingCohen’s benchmarks for small, medium, and large as 0.2,0.5, and 0.8, respectively (Cohen, 1988), confidence inter-vals surrounding these effect sizes should be consideredwhen interpreting these results.

ResultsOf the 15 studies that met the inclusion criteria, 8 addressed

the effects of OMEs on speech physiology (Question 1),8 addressed sound production (Question 2), and 5 addressedfunctional speech outcomes (Question 3). This total exceeds15 because several studies addressed more than one of theclinical questions.

Clinical Question 1: What Is the Influence of OMEson Speech Physiology?

Of the eight studies reporting data related to OMEsand speech physiology outcomes, five met the criteria forefficacy studies, and three met criteria for exploratory studies.

Efficacy StudiesTable 2 provides a detailed description of the interventions

and participants reported in the efficacy studies. The fivestudies incorporated a wide range of participants, interven-tions, and treatment schedules. Christensen and Hanson(1981) examined the effectiveness of OMEs (specificallytongue thrust treatment with neuromuscular facilitation tech-niques) combined with articulation treatment relative toarticulation treatment only in treating first graders with asevere tongue thrust. Another study (Korbmacher, Schwan,Berndsen, Bull, & Kahl-Nieke, 2004) focused on childrenwith multiple orofacial dysfunctions and compared twodifferent OME programs for tongue thrusting (i.e., traditionalmyofunctional treatment and an orofacial exercise pro-gram incorporating a training device called a “face former”).The three remaining studies (Backman, Grever-Sjolander,Holm,& Johansson, 2003; Carlstedt, Henningsson, &Dahllof,2003; Carlstedt, Henningsson, McAllister, & Dahllof, 2001)compared the use of oral stimulating plates and OMEs (i.e.,oral motor and sensory stimulation or SLP-designed physio-therapy program) with OMEs alone in young children with

TABLE 1. Quality indicators.

Indicator Quality marker

Study design • Controlled trial• Cohort study• Retrospective case control or single-subject design• Case series• Case study

Blinding • Assessors blinded• Assessors not blinded or not stated

Sampling/allocation • Random sample adequately described• Random sample inadequately described• Convenience sample adequately described• Convenience sample inadequately describedor hand-picked sample or not stated

Group/participant comparability • Groups/participants comparable at baseline on importantfactors (between-subjects design) or participant(s) adequatelydescribed (within-subjects design)

• Groups/participants not comparable at baseline or comparability notreported or participant(s) not adequately described

Outcomes • At least one primary outcome measure is valid and reliable.• Validity is unknown but appears reasonable; measure is reliable.• Invalid and/or unreliable

Significance • P value reported or calculable• P value neither reported nor calculable

Precision • Effect size and confidence interval reported or calculable• Effect size or confidence interval, but not both, reported or calculable• Neither effect size nor confidence interval reported or calculable

Intention-to-treat (controlled trials only) • Analyzed by intention-to-treat• Not analyzed by intention-to-treat or not stated

Note. Boldface indicates highest level of quality marker.



TABLE 2. Participant and treatment characteristics—speech physiology efficacy studies (Question 1).

Citation N Age Gender

Medical and/orSLP diagnosisas reportedin article Intervention

Treatmentschedule and

amountOutcomemeasure(s) Significance

Effect size(95% confidence

interval)

Qualitymarkerscore

Backmanet al. (2003)

106 15–22 months;M = 18.3 months

60 M, 46 F Downsyndrome

Intervention group—oral stimulatingplates and oralmotor sensorystimulation

Plates worn2–3 times perday for periodsof 5–30 min

SLP perception ofmotor prerequisitesfor articulation.

NR NR 1/8

Control group 1(age-matchednondisordered)—no treatment

Control group—not reported

Control group2—oral motorand sensorystimulation

Carlstedtet al. (2001)

20 3–33 months 12 M, 8 F Downsyndrome

Intervention group—oral stimulatingplate therapy plusphysiotherapyprogramdesigned by SLP

Plates worn for1 hr 2–3 timesper day for aminimum of4 years (range =49–58 months)

Clinical examinationof lip roundingduring speech

p < .01 NR 5/8

Control group—physiotherapyprogramdesigned by SLP


Video registration ofpercentage oftongue protrusionduring speech

NS 0.25 (–0.65–1.12)


20 3–33 months 12 M, 8 F Downsyndrome

Intervention group—oral stimulatingplate therapy plusphysiotherapyprogramdesigned by SLP

Plates worn for1 hr 2–3 timesper day for aminimum of4 years (range =49–58 months)

Clinical examinationof articulatoryplacement

NS NR 2/8

Control group—physiotherapyprogramdesigned by SLP


(table continues)

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TABLE 2 (continued ).






interval)

Qualitymarkerscore

Christensenand Hanson(1981)

10 5;8 (years;months)–6;9;

M = 6;2

6 M, 4 F Severe anteriortonguethrust andacousticallyseverefrontal lisp

Intervention group—tongue thrusttreatmentincorporatingneuromuscularfacilitationtechniques forfirst 6 weeksfollowed byalternatingsessions oftongue thrustand articulationtreatment for thenext 8 weeks.

All participants (bothintervention andcontrol group)received a totalof 22 individual2-hr treatmentsessions.Therapy wasprovided once aweek for 6 weeksfollowed by twicea week for 8 weeks.

Tongue tipplacement onlingua-alveolarsounds

NS 0.34 (–0.94–1.56) 6/8

Control group—traditionalarticulationtreatment

Korbmacheret al. (2004)

45 3;11–16;11;M = 8;4

32 M, 13 F Multipleuntreatedorofacialdysfunctions

Intervention group—face formertherapy, whichconsisted of aseries of lip andtongue exerciseswith a flexiblesilicone trainingdevice

Control group—conventionalmyofunctionaltherapy

Both groups werefollowed for6 months.

Intervention groupperformed20 repetitionsof the exercises3 times per day.After 3 weeks, thetraining device wasworn overnight.

Control group—notreported

SLP examinationof movementpatterns duringproduction ofalveolar sounds.

NS NR 4/8

Note. SLP = speech-language pathologist; NR = not reported or calculable; NS = not significant.

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Down syndrome. Amount, duration, and intensity of treatmentvaried greatly among studies. Duration of treatment rangedfrom 14 weeks to 58 months across studies, and frequency ofintervention ranged from once a week to three times per day.For all but one of the studies (Christensen & Hanson, 1981),the treatment schedules for the control groups were not stated.

Table 3 summarizes the quality marker ratings for eachstudy. All five studies were controlled trials, and most (four)reported data in a manner in which statistical significancewas calculable. However, the studies achieved poor qualitymarker ratings for the following areas: sampling/allocation,blinding, and intention-to-treat. Specifically, description ofthe comparability between groups was adequately reportedin only one study (Korbmacher et al., 2004), and analysis ofdata by an intention-to-treat protocol was noted in only onestudy (Christensen&Hanson, 1981). In addition, the blindingof the assessors to the treatment condition was indicated inonly two studies (Christensen & Hanson; Korbmacher et al.).

Two of the studies provided sufficient information andused measures of speech physiology for which treatmenteffect sizes were calculable. In Christensen and Hanson (1981),OMEs plus articulation treatment had a small positive effect(d = 0.34) over articulation treatment alone in tongue tipplacement on lingua-alveolar sounds. Carlstedt et al. (2001)also reported a small positive effect (d = 0.25) of oral stimulat-ing plates in addition to OMEs over OMEs alone for onedependent variable—percentage of tongue protrusion duringspeech. The OMEs group showed significant improvementon another dependent variable, clinical examination of liprounding during speech; however, an effect size was notreported or calculable. Three other studies provided furtherevidence on the effects of OMEs, although effect sizes werenot reported or calculable. Two studies (Carlstedt et al., 2003;Korbmacher et al., 2004) reported no significant changes inspeech physiology outcomes following OMEs, and one study(Backman et al., 2003) did not provide sufficient data toanalyze the findings statistically.

Exploratory StudiesThe three exploratory studies examined the use of orofacial

myofunctional therapy and orofacial physiotherapy, primarilyin participants with lip and tongue dyskinesias, and somewith cerebral palsy or dysarthria secondary to right hemispherebrain damage (see Appendix A). However, they were notconsidered efficacy studies because none used an experimentalor quasi-experimental design. Two studies reported no changes(Ray, 2001, 2002), and one study reported positive changes(Daglio, Schwitzer, Wuthrich, & Kallivroussis, 1993) inspeech physiology subsequent to OME. None of the studies,however, used experimental controls, and methodologicallimitations precluded the calculation of effect sizes.

Clinical Question 2: What Is the Influenceof OMEs on Sound Production?

Four efficacy studies and four exploratory studies inves-tigated the effects of OMEs on sound production as assessedthrough both formal and informal measures.

Efficacy StudiesAs noted in Table 4, the four efficacy studies included in this

review addressed a variety of populations and interventions.

Two studies (Baskervill, 1976; Christensen & Hanson, 1981)compared the effectiveness of articulation treatment plus neuro-muscular facilitation or myofunctional treatment to articula-tion treatment alone in school-age children exhibiting sibilantdistortion and tongue thrust. The third study (Carlstedt et al.,2003) evaluated the use of oral stimulating plates combinedwith OMEs compared to OMEs only in young children withDown syndrome. The fourth study (Logemann, Pauloski,Rademaker, & Colangelo, 1997) examined the effects of rangeof motion and coordination exercises of the lips, tongue, jaw,and larynx in individuals with head and neck cancer.

Table 5 summarizes the methodological quality ratingsfor each of the four studies. Three of the four studies werecontrolled trials; therefore, all eight quality markers wereapplicable. Logemann et al. (1997) was considered a cohortstudy, so the eighth marker (intention-to-treat analysis) wasnot relevant. Most of the studies (three) had valid and reliableoutcome measures, and reported or supplied sufficient datato calculate statistical significance. One study (Christensen& Hanson, 1981) reported blinding of the assessors to thetreatment condition and data analysis by an intention-to-treatstandard. Neither random allocation of participants to groupsnor adequate description of randomization procedures ormethods taken to ensure participant comparability betweengroups was reported in any of the included studies.

Cohen’s d values were calculated for two studies(Christensen & Hanson, 1981; Logemann et al., 1997).The three effect sizes ranged from –0.69 to 0.19. The twoeffect sizes calculated from Christensen and Hanson (1981)both favored articulation treatment alone over articulationtreatment plus OME. A small effect (d = –0.44) was notedon the total number of /s/ and /z/ errors, and a medium ef-fect (d = –0.69) on Goldman Fristoe Test of Articulationscores (Goldman & Fristoe, 1972). Logemann et al. reporteda negligible effect (0.19) for the use of OMEs (i.e., rangeof motion exercises) for improving speech sound productionas measured by the Fisher–Logemann Test of ArticulationCompetence (Fisher & Logemann, 1971). Two other efficacystudies also addressed this question, but effect sizes werenot calculable. One study (Carlstedt et al., 2003) reportedno significant improvements in speech sound productionfollowing OMEs, and the other study (Baskervill, 1976) didnot report or supply adequate data to calculate statisticalsignificance for differences on the McDonald Deep Testof Articulation (McDonald, 1964).

Exploratory StudiesFour exploratory studies addressed this clinical question

and examined the use of various OMEs in school-agechildren (see Appendix B). Two studies (Guisti Braislin &Cascella, 2005; Powers & Starr, 1974) reported no signif-icant changes in speech sound production following OMEs,and two studies (Fischer-Brandies, Avalle, & Limbrock,1987; Ray, 2003) did not provide sufficient data to analyzethe findings statistically.

Clinical Question 3: What Is the Influenceof OMEs on Functional Speech Outcomes?

Six studies related to OMEs and functional speech out-comes (i.e., intelligibility) were identified. Two of the studies



TABLE 3. Appraisal summary of speech physiology efficacy studies (Question 1).

CitationStudydesign Blinding Allocation Subjects Outcomes Significance Precision Intention-to-treat

Backmanet al. (2003)

Controlledtrial

Not stated Conveniencesample/hand-pickedsample

Comparability notreported

Invalid and/or unreliable P value neitherreported norcalculable

Neither effect size norconfidence intervalreported or calculable

Not stated


Controlledtrial

Assessorsnot blinded

Random sampleadequatelydescribed


At least one primaryoutcome measureis valid and reliable

P value reportedor calculable

Effect size andconfidence intervalreported or calculable

Not stated


Controlledtrial


Random sampleinadequatelydescribed


Validity unknownbut appears reasonable;reliable



Not stated


Controlledtrial

Assessorsblinded



At least one primaryoutcome measure isvalid and reliable


Effect size andconfidence intervalreported or calculable

Analyzed byintention-to-treat

Korbmacheret al. (2004)

Controlledtrial

Assessorsblinded


Groups comparableat baseline onimportant factors(between-subjectsdesign)

Invalid and/or unreliable P value reportedor calculable


Not analyzed byintention-to-treat

Note. Boldface indicates highest level of quality in each category.

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TABLE 4. Participant and treatment characteristics—sound production efficacy studies (Question 2).



Treatmentschedule

and amountOutcomemeasure(s) Significance


interval)

Qualitymarkerscore

Baskervill(1976)

5 8–10years

4 M, 1 F Reverseswallowingpattern andsibilantdistortions

Intervention group—Speech ImprovementProgram (SIS), anaudio-taped articulationprogram focusing onauditory discriminationproduction andstabilization plusmyofunctionaltreatment targetingstrengthening oforofacial musculatureand tongue as well astongue tip placementduring swallowing

Control group—SIS only

16 sessionswere scheduledfor 30–45 min,3 times per week.

McDonald Deep Testof Articulation(McDonald, 1964)

NR NR 2/8

Carlstedt et al.(2003)

20 3–33months

12 M, 8 F Down syndrome Intervention group—oralstimulation plate therapyplus physiotherapyprogramdesignedbySLP

Control group—physiotherapy programdesigned by SLP

Plates were wornfor 1 hr 2–3 timesper day for aminimum of4 years (range =49–58 months).

Control group—notreported

Clinician judgmentof consonantproduction

NS NR 2/8


10 5;8–6;9;M = 6;2

6 M, 4 F Severe anteriortongue thrustand acousticallysevere frontallisp

Intervention group—tongue thrusttreatment incorporatingneuromuscular facilitationtechniques for first6 weeks followed byalternating sessions oftongue thrust andarticulation treatmentfor the next 8 weeks.

Control group—traditionalarticulation treatment

All participants (bothintervention andcontrol group)received a totalof 22 individual2-hr treatmentsessions. Therapywas providedonce a week for6 weeks followedby twice a weekfor 8 weeks.

Total number of /s/and /z/ errors

Goldman FristoeTest of Articulation(Goldman &Fristoe, 1972)

NS

NS

–0.44 (–1.65–0.86)

–0.69 (–1.9–0.64)

6/8

Logemannet al.(1997)

102 Notreported

Notreported

Surgically treatedoral andoropharyngealcancer

Instruction in range ofmotion and/orcoordination exercisesof the lips, tongue, jaw,and larynx.

Participants wereinstructed toperform thegroup ofexercises for5–10 min,10 times per day.

Fisher–LogemannTest of ArticulationCompetence(Fisher &Logemann, 1971)

NS 0.19 (–0.23–0.6) 3/7

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TABLE 5. Appraisal summary of sound production efficacy studies (Question 2).

Citation Study design Blinding Allocation Subjects Outcomes Significance Precision Intention-to-treat

Baskervill(1976)

Controlledtrial


Comparabilitynot reported


P value neitherreported norcalculable

Neither effect sizenor confidenceinterval reported orcalculable



Controlledtrial




Validity unknown butappears reasonable;reliable



Not stated


Controlledtrial

Assessorsblinded





Effect size andconfidenceinterval reportedor calculable

Analyzed byintention-to-treat

Logemannet al. (1997)

Cohortstudy






Not applicable


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met the criteria for efficacy research, and four met those forexploratory research.

Efficacy StudiesOf the two efficacy studies addressing this clinical ques-

tion (see Table 6), one was a controlled trial examining theeffects of two different OMEs (OMEs with oral stimulat-ing plate compared with OMEs alone) in children with Downsyndrome (Carlstedt et al., 2003); the other was a cohortstudy that described the changes associated with OMEs inparticipants with head and neck cancer (Logemann et al.,1997). The methodological quality ratings for each studyare reported in Table 7. Both studies reported or suppliedsufficient data to calculate statistical significance and effectsizes. Neither study provided an adequate description ofthe comparability between groups, used outcome measureswith known or reported validity and reliability, or allocatedparticipants with well-described randomization procedures.One study (Logemann et al., 1997) reported blinding of theassessors to the treatment condition.

Three effect sizes were calculable from these two studiesand ranged from –0.56 to 0.4. The two effect sizes calculatedfrom Carlstedt et al. (2003) favored OMEs only over OMEsplus oral stimulating plates. A medium effect (d = –0.56) wasnoted on parent perception of participants’ intelligibilityto family members and a negligible effect (d = –0.02) forparent perception of participants’ intelligibility to strangers.The small effect size (d = 0.4) calculated from Logemannet al. (1997) described the positive change in intelligibilityof conversational speech for participants performing rangeof motion exercises versus those who did not.

Exploratory StudiesThree exploratory studies contributed data to address this

clinical question (see Appendix C). The studies examinedthe use of OMEs in participants with dysarthria secondaryto various etiologies including traumatic brain injury, stroke,and cerebral palsy. These studies only used pre- and posttestdesigns. No significant changes were noted in measures ofintelligibility of sentences or conversations (Ray, 2002). Twostudies (Ray, 2001, 2002) reported significant positive changesin single word intelligibility, and one study (Jones et al.,2006) did not provide sufficient data to analyze the findings.

Effect of Study Quality on ResultsResults from included studies were analyzed to determine

whether variations in study quality were associated withvariations in effect size. However, because there were onlyminimal discrepancies among the included studies in qualityor effect sizes, no conclusions were possible.

DiscussionFew treatment strategies in speech-language pathology

have generated as much interest and controversy as non-speech OMEs directed at speech improvement (Powell,2008; Watson & Lof, 2008). This systematic review doeslittle to resolve the controversies surrounding the use ofOMEs. The conclusion that must be drawn from this reviewis that the existing research literature provides insufficientevidence to support or refute the use of nonspeech OMEs.

The difficulty of examining OMEs and speech productionis multifold. First, very few articles have been publishedexamining the efficacy of nonspeech oral motor activitiestoward improving speech production. Moreover, many ofthe efficacy articles included in this EBSR did not compareOMEs with more traditional treatment approaches. Instead,these articles compared one OME intervention with a dif-ferent OME intervention (as defined by this EBSR). Thesetypes of studies make it difficult to ascertain not only theabsolute efficacy of OMEs but also their relative efficacycompared to existing alternatives. Furthermore, many of thearticles that do exist could not be included in this reviewbecause they did not address the effectiveness of OMEsalone and instead targeted the use of OMEs in combinationwith other treatment approaches. While this combinationapproach is often used clinically (Joffe & Pring, 2008; Lof &Watson, 2008), it is not possible to determine the true impactand added value of an intervention if it is not examined sep-arately or controlled for within a research design.

An additional important study was a literature review ofnonspeech oral motor treatments (Lass & Pannbacker, 2008)that was published as this article was being finalized. Al-though that article addressed a similar, although not iden-tical, topic to the one addressed here, its methods differed innumerous respects from the present one. These differencesincluded its treatment of both articulation and voice as “speech”outcomes, its inclusion of presentations and non-peer-reviewedarticles as possible sources of evidence, its acceptance ofstudies incorporating mixed treatments, and its use of differ-ent appraisal methods. Additionally, the overlap betweenthis review and Lass and Pannbacker’s results is small. Of the15 studies included in Lass and Pannbacker’s article, only3 are common to this EBSR. These differences prevent adetailed comparison of the results of that article and thosereported here. In general, however, Lass and Pannbacker’sconclusions are similar in that they cite a lack of sufficientevidence supporting the use of OMEs. However, they alsointerpreted their findings as supporting the conclusion thatOMEs “should be excluded from use as a mainstream treat-ment until there are further data” (p. 408), a broad conclusionwe could not reach based on the data presented here.

Other articles addressing the effects of OMEs were ex-cluded from this analysis. For example, several narrativereviews (e.g., Clark, 2003; Marshalla, 2008) were not in-cluded because they provided a summary of various OMEsand techniques but did not address the efficacy of any par-ticular approach. Other articles were excluded from thisEBSR because they were not published in the peer-reviewedliterature. Limiting articles to those appearing in journalsthat incorporate independent scrutiny as part of their pub-lication process is a reasonable step to ensure that someinitial vetting of the research has taken place, but even doingthis has shortcomings. Despite being published in the peer-reviewed literature, many of the included articles exhibitedmethodological weaknesses, specifically inadequate de-scription of protocols, interventions, and participants, as wellas lack of blinding. Adequate and thorough descriptionsof treatment protocols and interventions are necessary to al-low for replication by researchers and clinicians. Additionally,given that an important aspect of reviewing the existing



TABLE 7. Appraisal summary of functional speech outcomes efficacy studies (Question 3).

Citation Study design Blinding Allocation Subjects Outcomes Significance Precision Intention-to-treat

Carlstedtet al.(2003)

Controlledtrial

Assessorsnotblinded



Validity unknownbut appearsreasonable;reliable




Logemannet al.(1997)

Cohortstudy

Assessorsblinded

Conveniencesample/hand-pickedsample


Validity unknownbut appearsreasonable;reliable



Not applicable


TABLE 6. Participant and treatment characteristics—functional speech outcomes efficacy studies (Question 3).



Treatmentschedule



interval)

Qualitymarkerscore

Carlstedt et al.(2003)

20 3–33 months 12 M,8 F

Downsyndrome

Intervention group—oral stimulatingplate therapy plusphysiotherapy programdesigned by SLP

Plates worn for1 hr 2–3 timesper day for a minimumof 4 years (range =49–58 months)

Parent perceptionof intelligibilityto family

NS –0.56 (–1.43–0.36) 3/8

Control group—physiotherapyprogram designed bySLP


Parent perceptionof intelligibilityto strangers

NS –0.02 (–0.9–0.87)

Logemannet al. (1997)

102 NR NR Surgically treatedoral andoropharyngealcancer

Instruction in rangeof motion and/orcoordination exercisesof the lips, tongue, jaw,and larynx.

Participants wereinstructed toperform the groupof exercises for5–10 min, 10 timesper day.

Percentageintelligibility ofconversationalspeech

NS 0.4 (–0.05–0.84) 3/7

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evidence is to interpret the results in light of the patient orpatients for whom one is considering a particular treatment,a comprehensive participant description is essential. Drawingconclusions from evidence is difficult when few details (e.g.,concomitant deficits, severity of the disorder, or cognition)about the participants of the study are provided. Part ofevidence-based practice involves determining which tech-niques are appropriate and potentially effective for particularpopulations. Another important aspect of reviewing evidenceis to control for potential subjective bias. One safeguardthat is often used is blinding. Studies that do not incorporateblinding (most of the studies reviewed here did not im-plement blinding) may introduce systematic bias, whichcan influence the study findings by inflating the effects ofthe intervention (Wood et al., 2008).

A final problem in interpreting the results of this sys-tematic review is that even within the small corpus of studiesthat do exist, there is a great deal of variability among thestudies in the populations, types of OME, and outcomesinvestigated. For example, the participants included in thisEBSR ranged from infants to elderly adults who exhibiteda wide variety of medical diagnoses and communicationdisorders, including mild articulation disorder, Down syn-drome, cerebral palsy, stroke, cleft palate, traumatic braininjury, tongue thrust, and oral or oropharyngeal cancer.Moreover, the types of OMEs used in these studies wereequally diverse. Given the breadth of the definition of OMEsused for this EBSR, many types of OMEs were examinedand included such different interventions as oral stimulatingplates, myofunctional therapy, range of motion exercises,strengthening exercises, sensory stimulation, and blowing/sucking exercises. Attempting to generalize the findings ofsuch a disparate group of studies for clinical decision makingis not only problematic but ill-advised.

As Sackett, Rosenberg, Gray, Haynes, and Richardson(1996) note, evidence-based practice entails explicit use ofthe current best evidence from systematic research when mak-ing decisions about treatment. Another principle of evidence-based practice is the integration of individual clinicalexperience with that best research evidence. On the surface,that may seem to give clinicians permission to rely on pre-vailing and commonly used treatment. However, Sackett andcolleagues also note that “it is when asking questions abouttherapy that we should try to avoid the nonexperimentalapproaches, since these routinely lead to false positive con-clusions about efficacy” (p. 72). Therefore, relying on clinicalexperience alone and prevailing popular techniques may notbe a wise way to select a specific treatment approach.

Despite the shortcomings of the evidence base for infor-mation about the value of OMEs, there are still a numberof strategies to help clinicians in making the best clinicaldecisions regarding treatments designed to influence speech.These include implementing efficacious treatments—forpopulations and problems for which these have been iden-tified, understanding the theoretical frameworks and evi-dence for relevant areas of basic research (e.g., speechphysiology or motor learning), and examining untestedtreatment approaches under controlled conditions.

Probably the best option available is for clinicians to seekout alternative speech treatments whose efficacy has already

been established in the literature. Especially when speechproduction or functional speech outcomes are the ultimategoals of intervention, treatments that directly work towardthose outcomes have been proposed and studied for a largenumber of populations. For example, for adult patients, sev-eral systematic reviews have documented the effects of speechtreatments focusing on vocal loudness, vocal effort, andpitch for improving intelligibility in individuals with dysar-thria and Parkinson’s disease (Yorkston, Hakel, Beukelman,& Fager, 2007; Yorkston, Spencer, & Duffy, 2003). In thearea of children’s speech sound disorders, a number of in-terventions have been supported for use with relativelywell-defined populations—for example, minimal pairs (e.g.,Ruscello, Cartwright, Haines, & Shuster, 1993) and cycles(e.g., Almost & Rosenbaum, 1998; Hodson, Nonomura,& Zappia, 1989).

A second option is presented in the form of basic researchproviding evidence on the underlying mechanisms by whichOMEs could be expected to work—for example, evidenceregarding speech physiology, speech development, andmotorlearning (e.g., Bunton, 2008; Clark, 2003, in press; Maaset al., 2008; Wilson, Green, Yunusova, & Moore, 2008).Discussions of evidence-based practice frequently note thatbecause basic research does not directly address clinical ques-tions, it is best used to help set the stage for research thatdoes (e.g., Dollaghan, 2007). Nonetheless, when clinicalevidence is missing, such research may suggest whetherspecific rationales or approaches are reasonable. For exam-ple, if clinicians are concerned about low tone affecting aclient’s tongue or lips, knowledge of anatomy (specificallythe differences in muscle spindle distribution in those struc-tures) and physiology (in particular, the role of the musclespindles in activating the stretch reflex) would cause themto question the use of an OME (e.g., quick stretch) intendedto accomplish increases in tone through the stretch reflex(Clark, 2003). Similarly, if clinicians are concerned about theabsence of /t,d/ in a child’s repertoire, knowledge of motorlearning (such as the importance of targeting complex move-ments as a whole; Maas et al., 2008) would cause them toquestion the use of an OME (e.g., tongue tip elevation outsideof speech) intended to improve alveolar placements in speech.Although Sackett and colleagues (1996) note that basic re-search conducted on a nonclinical population should not bethe first place for evidence-based practice oriented cliniciansto turn, such research provides a more solid base than anec-dotal testimonials or expert opinions.

A third option open to clinicians seeking an efficacioustreatment for their clients with speech sound disorders in-volves implementing reasonable and logically sound treat-ment approaches with clients in a controlled, experimentalcontext. Undertaking an examination of treatment outcomes(internal evidence) for a client should always be a part of theclinical process (Baker & McLeod, 2004). However, likeexternal evidence, internal evidence can vary in quality. Forexample, whereas pre- and posttesting can help a cliniciangain some sense of whether change has occurred, the use of asingle-subject experimental design to track progress providesmore detailed information and, most importantly, helps torule out alternative explanations for that change, such asdevelopment or recovery (Barlow, Nock, & Hersen, 2009).



If clinicians choose to incorporate interventions with noexternal evidence into a client’s treatment plan, the clientshould be informed that the treatment is exploratory (Duchan,Calculator, Sonnemeier, Diehl, & Cumley, 2001), and cli-nicians should carefully evaluate the effects of the treatmentwithin a controlled treatment design.

Limitations of the Current ReviewThere are several limitations of this EBSR that should

be considered. First, only articles published in English wereincluded in this review. Given this, it is possible that somestudies addressing the effectiveness of OMEs were not iden-tified. Additionally, many of the identified studies were ex-cluded because they did not address one of the targetedoutcomes outlined in the clinical questions. If the clinicalquestions of this EBSR had been expanded to include out-comes such as increased strength or range of motion, morestudies would have been available for analysis. Finally, asnoted above, the wide variation across studies in terms ofparticipants, interventions, and outcomes meant that therewas no common denominator, such as a shared outcomemeasure, on which to evaluate OMEs or with which to con-duct a comparative analysis of effect sizes.

ConclusionThis systematic review was designed to examine the cur-

rent evidence for the use of nonspeech OMEs toward im-proving speech production. The current state of evidenceis equivocal due to the lack of well-designed, experimentallycontrolled studies with adequate statistical power and well-described participants. Given this, clinicians must considercarefully what a particular oral motor activity is likely toaccomplish and whether it addresses the impairment theclient actually exhibits (based on the knowledge bases dis-cussed above). At this time, based on theory and availableevidence, the use of OMEs must be considered exploratory,and clients should be informed of this prior to initiating theiruse in treatment.

Future research efforts on OMEs should focus on estab-lishing the efficacy of specific approaches through well-designed single-subject and group experimental studies thatprovide adequate descriptions of participants and interven-tions, control for the influence of variables outside of treat-ment, and incorporate reliable and valid outcome measures.Only by growing the research evidence base can clinicianscontinue to improve their ability to make sound clinicaldecisions.

AcknowledgmentsThis evidence-based review was supported by ASHA’s N-CEP.

We thank the following individuals who participated in the evidencepanel to review the state of the evidence on nonspeech oral motorexercise: Dr. Joan Arvedson, Dr. Heather Clark, and Dr. CathyLazarus. We also thank the following individuals who contributedto the preparation of this document: Beverly Wang, N-CEP Infor-mation Manager; Hillary Leech, N-CEP Research Assistant; andRob Mullen, N-CEP Director.

ReferencesReferences marked with an asterisk indicate studies

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*Backman, B., Grever-Sjolander, A. C., Holm, A. K., &Johansson, I. (2003). Children with Down syndrome: Oraldevelopment and morphology after use of palatal plates between6 and 18 months of age. International Journal of PaediatricDentistry, 13, 327–335.

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Barlow, D. H., Nock, M. K., & Hersen, M. (2009). Single caseexperimental designs: Strategies for studying behavior change(3rd ed.). Boston: Pearson/Allyn & Bacon.

*Baskervill, R. D. (1976). The effects of special speech therapeuticprocedures involving individuals with sibilant distortions: Apilot study. International Journal of Oral Myology, 2, 86–92.

Bunton, K. (2008). Speech versus nonspeech: Different tasks, dif-ferent neural organization. Seminars in Speech and Language,29, 267–276.

*Carlstedt, K., Henningsson, G., & Dahllof, G. (2003). A four-year longitudinal study of palatal plate therapy in childrenwith Down syndrome: Effects on oral motor function, articu-lation and communication preferences. Acta OdontologicaScandinavica, 61, 39–46.

*Carlstedt, K., Henningsson, G., McAllister, A., & Dahllof, G.(2001). Long-term effects of palatal plate therapy on oral motorfunction in children with Down syndrome evaluated by videoregistration. Acta Odontologica Scandinavica, 59, 63–68.

*Christensen, M. S., & Hanson, M. L. (1981). An investigationof the efficacy of oral myofunctional therapy as a precursor toarticulation therapy for pre-first grade children. Journal ofSpeech and Hearing Disorders, 46, 160–167.

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*Daglio, S. D., Schwitzer, R., Wuthrich, J., & Kallivroussis, G.(1993). Treating orofacial dyskinesia with functional physio-therapy in the case of frontal open bite. The InternationalJournal of Orofacial Myology, 19, 11–14.

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*Fischer-Brandies, H., Avalle, C., & Limbrock, G. J. (1987).Therapy of orofacial dysfunctions in cerebral palsy according to



Castillo-Morales: First results of a new treatment concept.European Journal of Orthodontics, 9, 139–143.

Fisher, H. B., & Logemann, J. A. (1971). The Fisher–LogemannTest of Articulation Competence. Boston: Houghton-Mifflin.

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*Guisti Braislin, M. A., & Cascella, P. W. (2005). A preliminaryinvestigation of the efficacy of oral motor exercises for childrenwith mild articulation disorders. International Journal ofRehabilitation Research, 28, 263–266.

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*Jones, H. N., Donovan, N. J., Sapienza, C. M., Shrivastav, R.,Fernandez, H. H., & Rosenbek, J. C. (2006). Expiratory mus-cle strength training in the treatment of mixed dysarthria ina patient with Lance-Adams syndrome. Journal of MedicalSpeech-Language Pathology, 14, 207–217.

*Korbmacher, H. M., Schwan, M., Berndsen, S., Bull, J., &Kahl-Nieke, B. (2004). Evaluation of a new concept of myo-functional therapy in children. The International Journal ofOrofacial Myology, 30, 39–52.

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*Powers, G. L., & Starr, C. D. (1974). The effects of muscleexercises on velopharyngeal gap and nasality. The Cleft PalateJournal, 11, 28–35.

*Ray, J. (2001). Functional outcomes of orofacial myofunctionaltherapy in children with cerebral palsy. The InternationalJournal of Orofacial Myology, 27, 5–17.

*Ray, J. (2002). Orofacial myofunctional therapy in dysarthria:A study on speech intelligibility. The International Journal ofOrofacial Myology, 28, 39–48.

*Ray, J. (2003). Effects of orofacial myofunctional therapy onspeech intelligibility in individuals with persistent articulatoryimpairments. The International Journal of Orofacial Myology,29, 5–14.

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Wood, L., Egger, M., Gluud, L. L., Schulz, K. F., Juni, P.,Altman, D. G., et al. (2008). Empirical evidence of bias intreatment effect estimates in controlled trials with different in-terventions and outcomes: Meta-epidemiological study. BritishMedical Journal, 336, 601–605.

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Received January 21, 2009Accepted May 8, 2009DOI: 10.1044/1058-0360(2009/09-0006)

Contact author: Tracy Schooling, National Center for Evidence-Based Practice in Communication Disorders, AmericanSpeech-Language-Hearing Association, 2200 ResearchBoulevard #245, Rockville, MD 20850-3289.E-mail: [email protected].



Appendix A

Summary of Speech Physiology Exploratory Studies (Question 1)

Citation NAge

(years) Gender

Medicaland/or SLPdiagnosis asreportedin article Intervention

Treatmentschedule


Qualitymarkerscore

Daglio et al. (1993) 75 6–22 22 M, 53 F Frontal openbite andlip/tonguedyskinesia

Functionalorofacialphysiotherapy

Not stated Proportion ofparticipantswith lisp basedon clinicalobservation

p < .001 1/7

Ray (2001) 16 7–10; M = 8.6 9 M, 7F Cerebralpalsy withmild tomoderatespasticityanddysarthricspeech

Orofacialmyofunctionaltreatmentprogram thatfocused on oralsensory stimulationand exercisesfor lips, tongue,jaws, and cheeks

Participantsreceived 25-minsessions (15 min ofindividual treatmentand 10 min of grouptreatment) 5 timesper week over4 months. Additionally,parents implementeda home-basedexercise program4–5 times per day.

Diadochokineticrate

NS 2/7

Ray (2002) 12 M = 74.7 Not reported Single righthemisphereischemicstroke andmild tomoderatedysarthria

Treatment focusedon oral sensorystimulationand strengtheningexercises for lips,tongue, jaws,and cheeks.

Participants received45-min treatmentsessions twiceweekly for 2 months.

Alternatingmotionrate

NS 2/7

Note. NS = not significant.

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Appendix B

Summary of Sound Production Exploratory Studies (Question 2)

Citation NAge

(years) Gender

Medicaland/or SLPdiagnosisas reportedin article Intervention



Qualitymarkerscore

Fischer-Brandeiset al. (1987)

71 4–14; M = 10 34 M, 37 F Cerebral palsy Removable stimulatory platesfor orofacial regulation therapy.Approximately 1/3 of theparticipants also received oraland facial physiotherapy.

Plates wereworn for anaverage of15 months(range =6–36 months).

Observation oflabial, palatal,and dentalsound production

NR 0/7

Guisti Braislinand Cascella(2005)

4 6;4–6;9(years;months);

M = 6;6

2 M, 2 F Mild functionalarticulationdisorder ofunknown origin

Easy Does It for Articulation:An Oral-Motor Approach(Strode & Chamberlain, 1997)

Participantsreceived 15 2-hrsmall-group (n = 2)treatment sessionsover 7 weeks.

Number oferrors onGFTA

NS 4/7

Powers andStarr (1974)

4 8–11 3 M, 1 F Palatal cleftrepaired beforeage 2 and mildto moderatenasality

Treatment consisted of 4 sets ofexercises: blowing and suckingexercises targeting velar muscleactivity, and swallowing and gaggingexercises focusing on pharyngealwall muscle activity.

Exercises wereperformed 4 timesper day, 5 daysper week, for6 weeks.

9-point equal-appearing scaleranging frommild nasality(1) to severenasality (9),immediateposttreatment

NS 2/7

At 6-week follow-up NS

Ray (2003) 6 18–23; M = 20 4 M, 2 F Anterior openbite with frontand lateral lisp;one participantdescribed as havingdevelopmentalverbal apraxia

Oral motor treatment focusingon tongue resting posturesand lip closure. Activitiesincluded holding a tonguedepressor between lips andholding the tongue tip onalveolar ridge for 15 minper day.

Participants received1 45-min treatmentsession per weekfor 6 weeks plusadditional homeassignments.

Percentage ofsingle words,sentences,and connectedspeech with nophonemic orphonetic errors.

NR 2/7

Note. NR = not reported or calculable; GFTA = Goldman Fristoe Test of Articulation (Goldman & Fristoe, 1972).

McC

auleyet

al.:OralM

otorExercises

System

aticReview

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Appendix C

Summary of Functional Speech Outcomes Exploratory Studies (Question 3)

Citation NAge

(years) Gender

Medicaland/or SLPdiagnosis asreportedin article Intervention

Treatmentschedule


Qualitymarkerscore

Jones et al. (2006) 1 26 1 F 4 years after severetraumatic brain injurywith complex mixeddysarthria andLance-Adamssyndrome

Expiratory musclestrength training—forceful exhalationagainst resistanceuntil a set level ofpressure is produced

Participant completed 25trials per day; 1 timeper week in clinic(5 trials; followed by5–10 min of rest) anddaily at home for6 months.

10 sentences,14 words each,from the AIDS,administeredposttreatment andat 3-month follow-up.

NR 2/7

Ray (2001) 16 7–10; M = 8.6 9 M, 7 F Cerebral palsywith mild tomoderatespasticity anddysarthricspeech

Orofacial myofunctionaltreatment programthat focused on oralsensory stimulationand exercises forlips, tongue, jaws,and cheeks

Participants received25-min sessions(15 min of individualtreatment and 10 minof group treatment)5 times per weekover 4 months.Additionally, parentsimplemented ahome-basedexercise program4–5 times per day.

5-point intelligibilityrating scale

p = .0023 4/7

Ray (2002) 12 M = 74.7 NR Single righthemisphereischemic strokeand mild tomoderatedysarthria

Treatment that focusedon oral sensorystimulation andstrengthening exercisesfor lips, tongue, jaws,and cheeks

Participants received45-min treatmentsessions twice weeklyfor 2 months.

5-point intelligibilityrating scale—single words

p < .001 3/7

Sentence andconversationalspeech

NS

Note. AIDS = Assessment for Intelligibility of Dysarthric Speech (Yorkston & Beukelman, 1984).

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