Ep 329: Identifying 'More Than Myo' Moments with Hallie Bulkin, MA, CCC-SLP, CMT®, CPFT™

Foreign. Welcome to the Untethered Podcast.

I am your host, Hallie Balkan. I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, airway.

Tether, Dural tissue and pediatric feeding therapy space.

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Hello my friends and welcome to episode 329 of the Untethered Podcast. This is your host, Hallie Balkan, and I want to dive into a question that I recently got inside of the MYO membership. It's a great one and it was, you know, what do we do when we hit that point in a case where our gut kind of says like, there's something more going on here, but I don't really know exactly what or even who to bring in, right? Who do I refer to? So we're going to talk through some like, red flags, if you want to call them that, team collaboration and building your referral instincts, especially in those complex or unclear cases. And I feel like I'm a good example of one of those. And going into Marpi, for example, after I've done other expansion, I've been in Mayo, right? Like, it's like something's got to give, something is not working as we intended. So let's, let's define this moment, right? So like when the more than MYO starts to show up, like you've got a patient, maybe things started off really straightforward, but then progress stalls or even regresses or like there's some like, atypical behavior or tone not previously noted, or maybe the oral motor patterns seem inconsistent or they don't match, like the age or the diagnosis. Right. That you thought you were going with. Right. Maybe the parent history doesn't align with what you're seeing clinically. Right. So this could be like obviously in some kids, but with adults, like maybe the patient's history doesn't align with what you're seeing clinically. And so the takeaway here is, like, when your Milo lens is no longer enough to explain the full clinical picture that is your, like, oh, this is more moment. Right? There's more than myo going on here. We needed, we need to make a referral. Right. So what I want to do is I want to spend a little time talking about who might be on the team and then we're going to dive into, like, what to look for. Okay. Because I want, like, the red flags, if you will, because I really like to focus a lot on collaboration and that requires a zooming out and considering the broader team at hand. Depending on, like, what's coming up, how the patient's presenting. Here's who you might consider. I know we've talked about this before, but I really wanted to just, like, spend an episode, like, focused on this because I think this is really important for, like, patients and providers and everybody on the team to hear, understand and know. And so who are the potential people we might be referring to? Well, ents. Right? So maybe if there's an unresolved airway issue, problem with nasal breathing that we think is structural. Right. Sleep, disordered breathing, tonsils, adenoids, tongue tie present. Obviously, you can also refer to other providers for help with tongue ties. You know, there's dentists that release, there are oral surgeons that release tongue ties, you know, not just ents per se, orthodontists even. And then also with, you know, some people are like, well, I, I don't want to go the traditional medicine route. Okay, so maybe you're going to go to a holistic doctor or practitioner who can help with decreasing inflammation, you know, in the tonsils or adenoids. Maybe you're going to go to, you're going to refer a patient or you're going to go to an allergist to see how you can help with any allergic responses. But I will say I have not taken my kids to an allergist anytime recently. Because when we did go and they were younger, they were like, well, we see the symptoms, but the tests are telling us everything's fine. But they're so young. It's also unreliable. And I'm like, oh, that's really conclusive and helpful. Anyways, I found Galba Sone, who is in the Boca and Hollywood, Florida areas, and she basically taught me that these responses and reactions, I'm sharing this for a reason, so stay with me. But these responses and reactions are happening because the immune system has determined this thing is not safe. And if we can teach the immune system that this is safe, all those quote unquote allergies or immune responses, right, they calm down, they go away, they, we resolve them. And so there's a lot of different ways that we can approach these things. So ENTS being one of them, oral surgeons, dentists, right. There's also, you know, you may also go to like a sleep doctor or a dentist for suspected sleep apnea, potential mouth breathing, bruxism. Right? You're grinding, maybe you're clenching, ADHD type symptoms that might be relating, you know, or maybe sleep related. Right? All kinds of things that could be going on. Right. Okay, then there's our OTS and pts for, you know, ot, we see more sensory processing help with, but also otpt for postural and stability, maybe any retained primitive reflexes, poor coordination. So if you're seeing anything along those lines, that would be your ots or pts, you know, speech pathologists. That's where we're going to send people for feeding swallowing concerns. So if it goes beyond like MYO covers the oral phase, just getting that bolus, that food that's mixed with saliva, chewed up and prepped and ready to swallow, the second that you trigger the swallow, that is no longer myo, that is now feeding, dysphagia therapy, or talking about like food leaving the oral cavity and moving into the pharynx, moving into the throat. So that goes to the oral pharynx and that becomes the slp. They're the only ones that can actually treat like a swallowing disorder. Whereas other professionals like otp, SLP can all deal with feeding, you know, in the oral cavity. RDH is, and dentists also, through a MYO lens can deal with, you know, that bolus prep. So, so I like to clarify that. So you're like, well, who do I send them to? Well, what else is going on? Right? If there's some expressive or receptive language delays or disorders, or resonance issues or articulation issues. Right. And so on and so forth. Like your SLP will be the person who you would probably go to for all of them. Not who you probably would. That's who you would also go to for these issues. Body workers. So your chiropractors, your cranial sacral, cranial fascial therapist, myofascial therapist. Myofascial, not to be confused with myofunctional, your osteopaths. Right? All of these individuals are going to help with any like persistent oral tension. They may also look at like any dysregulation between the suck, swallow, breathe pattern, which is something that is treated directly through like feeding therapy or even with like an IBCLC or lactation specialist, if we're talking about little babies, but babies don't do mayo. Right. So we're really focused here more on your older kids, your kids who are of appropriate MYO age, which you need the cognitive abilities of a four to five year old to engage in myofunctional therapy because a lot of it is volitional. And what we ask children to do at that age is going to be too challenging for a younger child. But total sidebar here, I do teach through my Feed the peeds course, how to do feeding with a twist of tots and mayo, where we basically adapt the goals of mayo into our feeding program. So any feeding therapist, slp, OTPT, could also integrate the MYO stuff into their pediatric feeding sessions and address tetheral tissues tension, all that stuff, dysfunction, you know, dysregulation, just, you know, dysfunctional patterns, all those things. Right. Okay, back to it. So I've mentioned orthodontist, but also dentists for like tongue tie releases and some of these other things that we've mentioned already. But those orthos and airway focused dentists, you know, are going to look specifically at the skeletal discrepancies. Like we don't move bone for a living. As myofunctional therapists, we deal with tissue which can influence bone, but we can't make any promises. We can't say this is gonna affect that. We can say what changed afterwards and the changes that we've seen. If we're only doing myo, but we don't move bone for a living. Right. So any of those skeletal discrepancies, the bone movement, anything with the bite, any facial growth issues, dental crowding, poor tone space because of structural issues, like that's going to be that ortho or airway focused dentist. Right. And then I brought up lactation consultants and I do want to mention like lactation consultants or you know, other, like basically feeding therapists. If you have a child who's under the age of four and they're still breast or bottle feeding, you know, you're going to want to refer them. If you have a child over the age of four who is still breastfeeding, then, you know, lactation might be important. Now that is less common in the United States, but more common in other parts of the world where a lot of people do breastfeed beyond the age of. So I like to include that information here because it can be relevant in those situations, but less, less common in the US So my tip here is that, like, I don't want you to feel like you need to diagnose the issue or every issue. That's what your referrals are for. You just need to recognize, like, what's beyond your scope, who's the appropriate person to deal with this, no matter how complex the case is. Who do we think the next best referral source is going to be for this patient's issue? Right. And so that's where I kind of focus. That's why I like to run through, like, who might be on the team, what are we sending them, you know, why are we sending people to them so that people can really understand like why that referral has been made for you or your child or why you, as the provider, you know, should be referring out and who to refer to for what. Right. And so now I want to kind of focus on like, what should we be looking for, like, kind of red flags by system, if you will. So let's get a little more specific. Okay. I went through some of the symptoms before, but these are some of the common patterns and what they might point to. And so with sleep and breathing, you know, you might see mouth breathing, restless sleep, maybe there's some bedwetting happening, ADHD like, behaviors. And so I want you to think about when you see these things and you know, as they relate to like sleep and breathing. I want you to think about airway. Airway first, always tonsils and adenoids. And maybe the child or adult needs a sleep study. That might be where they're headed next. Okay, so that's sleep and breathing. Next would be sensory or regulation. So avoidance of oral input. So like anybody who's avoiding putting anything in their mouth, maybe they're avoiding just any kind of oral input. Maybe they don't actually like going to the dentist or the ortho because they feel like they like, it's. It's very. It's like an attack on their nervous system. Right. They have a hard time regulating how they feel with that. Maybe they are avoiding putting certain foods in their mouth. Maybe they're. Whatever may be going on, maybe they also are showing some inconsistent responses to therapy. And you're like, well, one day they seem really regulated, the next day they don't. That can be airway related. That can improve over the course of like, expansion or myo or, you know, improving the, the airway in general. But in the meantime, to help them really function well and Be functional in day to day. An OT referral might be really, really helpful to help give them strategies on regulating their nervous system, their sensory system. Right. Like kind of getting that sensory processing under wrap. So OT love our ot's for that structural. Now structural we mentioned like an ortho or airway dentist. Right. But when I say structural, what I'm talking about is like somebody who's prevent presenting with like a high palate. You know, their palate is really high in their mouth. Their arch, their dental arch might be kind of narrow. Maybe they have facial asymmetries, they may have an anterior tongue thrust. So certain things where like yes, this is going to go hand in hand with myofunctional therapy, but also like beyond the anterior tongue thrust, it's maybe you know, resting against the teeth and pushing those teeth out. So it is the, you know, the muscle is influencing the bone. Some of these other things are just straight up bone which is going to then influence the muscle, it's going to influence the tongue, like the high palate, the narrow arch, the facial asymmetry. Because you know, if you guys go back and listen to my recent episode where I talked about what I'm going to be doing with my Marpi journey, I really, really dove into some of the reasons why I'm going through this and facial asymmetry was a big one. So go back and listen to that if you have not already. Because it's short, it's sweet. But I think like you're going to get a really good glimpse into like where I'm at as a 40 year old woman and why I'm doing this. After I've had expansion as a child, embraces expansion as an adult already I've had a tongue tie release all the things. So anyways, okay. And then lastly functional stalling. So sometimes we see that people get really good gains early on, but then they kind of like plateau, right? There's stagnation. And so we need to reevaluate at this point. Like is there a tongue tie we missed? Or do we think that tongue tie is actually impacting things more than maybe we thought it was? And maybe we do want to head for a consult, a release consult. Right. Maybe there's body tension elsewhere that we need to release. Maybe there is a missing team member. Maybe there's somebody that we need to refer to that can help us kind of figure out like what are we missing here? Why are we plateauing? Right, you're, maybe you're not seeing why the plateau is happening. If the patient has not had a CBCT done, like a CT scan. Right. An actual scan of the bones, a facial scan. You know, maybe we want to send them for that because maybe we'll see something that we're missing with the naked eye that we're not going to see without a scan. Right. So just being open to, like, what are the patterns you're seeing, what might they point to? And then who are those professionals that we want to refer onward to? Right. And so the other piece here is we need to then have this referral conversation with either the patient or the family of the patient. Right. And so I find that a lot of clinicians hesitate to refer because they don't want to overwhelm families. And I think that's a beautiful thing. But referrals, especially when we only do one at a time and we frame it as a part of a whole team approach that builds trust and that actually can relieve some overwhelm and some tension and some fear or unknowns that a lot of family are carry. They're carrying around on their, like, all this excess weight on their shoulders because they just feel like, well, I'm doing this, but it's not working. But also I'm told I need to do this, so I don't want to stop it. So bringing in that additional person to actually solve that puzzle piece and kind of help continue moving things forward can be really, really great. So what you could even say, you know, professionals to families is, you know, we're seeing really great progress in some areas, but there's another piece that might be holding things back. I would love get a specialist involved who can help us go even further. Right. And so this positions the referral as a value add. Not a problem. Yes, it's an additional things for the parents to do, but it really adds value. And like I said, for a lot of families, it actually can help decrease the overwhelm. If you position this correctly and you tell them, like, I think this is the next part of the journey. Like, I think that this is the next best person to do a consult with because I think we've hit a wall. Here's why I think we've hit that wall. But I don't know for sure. And I feel like this consult will help us get more answers and allow us to know how best to move forward. And when you position it like that, right. It' like families are like, oh, okay, yeah, of course we want to do that. Like, obviously, we don't want to stall forever, so. And most of us don't want to spend our time or our money on things that are seemingly stalled. So, like, let's figure out how we move this forward. Right? Okay. The other thing I want to tell you guys is to kind of build out your toolbox here with when it comes to referrals and resources. So keep a referral tracker like, note which professionals you refer to, how they've helped and what you've learned, and then maybe ask other therapists. The beauty of, like being in the MYO membership, for example, is, you know, people can ask like, hey, who would you refer to for this? Or are this patient seeing this? Do you like, what do you think next steps might be? Or have you worked with this provider before? Who do you recommend here in this area? Right. So you can ask other therapists, like, who they refer to, and you can also even say to a patient, like, you know what? I'm not sure yet. I haven't found the person in our area. But let me reach out to somebody that I trust, you know, somebody and I trust for some guidance and let me see if they have a referral that they recommend that they work with regularly. And, you know, the other thing is I'm going to plug the MYO membership again because mentorship is so important. And so that's where being in a community like the MYO membership is so, so helpful because you're not alone in navigating these cases. So knowing when it's more than MYO doesn't make you a less skilled therapist. It actually makes you a very wise one. And this is how we continue to practice ethically and collaboratively and with the client's best interest at heart. And so, my friends, if you found this episode helpful, I want you to share it with a colleague. And as always, you can drop your questions or your tricky cases in our group if you're inside the MYO membership. If you're not, come and join us. Go to the myomembership.com we're going to work through all the cases together as we always do. So definitely come and join us. If you have any questions at all, you can always reach out to me at Hallie Balkan on Instagram. Until next episode, have a wonderful week and we'll talk to you soon.

Thanks for listening to this podcast. If you found value in this episode and want to hear more of these Myotots, Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts and share this episode on your social media platforms. You can access free resources and all I offer@halliebalkin.com or pop over to Hollybulcken on Instagram to get all the latest updates.