EP 340: Evidence vs. Pseudoscience in Myofunctional Therapy with Hallie Bulkin & Robyn Merkel-Walsh

Part of the problem is if you're not doing this every day, you don't know how to differentiate non speech oral motor exercise from an orofacial malfunctional therapy exercise from an oral placement exercise from myofascial release. And it's even the patients that call I have a baby, I need myofunctional therapy or I you know, I need to go for a tongue tie release and I'm looking for a myofascial therapist. Like all of this jargon, if the professionals don't know the right terminology, the patients are not going to know what to look for.

Hi and welcome to episode 340 of the Untethered Podcast. Today on the podcast I'm excited to welcome back Robyn Merkel Walsh, a nationally recognized leader in speech language pathology, Orofacial Myology and vocology. Robin brings over 30 years of experience as a New Jersey and New York licensed SLP Rock Certified Orofacial Myologist and vocalist. She works full time for the Ridgefield Board of Education and runs her private practice Diamond Myo and vocology in Richfield, New Jersey. She's been named a New Jersey Kids Top Doctor five times, is a four time ASHA ACE Award recipient, and was Ridgefield's Woman of the Year in business in 2019. Robin earned both her degrees from Montclair State University, where she later became an adjunct and clinical supervisor. She's also taught at Seton Hall, Russia University and Bergen Community College. Robin is a respected subject matter expert and advocate for evidence based practices with publications in clinical Pediatrics, Journal of Oral Rehabilitation, and the International Journal of Orofacial Myology, among others. She's co authored several Go to Clinical resources including OPT Goals for Speech Clarity and A Sensory Motor Approach to Feeding. As a speaker for Talk Tools, Robin teaches continuing Ed courses on oral placement therapy, TOTS, MyoTools, Airway, and more. She's been invited to present for Ashes by organizations like the Breathe Institute, AAPMD and the IOM. She also mentors clinicians, supports research, and volunteers in parent professional groups focused on opt tots and NCAs. Welcome to the Untethered Podcast. I am your host, Holly 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, Tetheral Tissue and Pediatric Feeding Therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019. Thanks for being a loyal listener. As we jump into today's episode, remember to listen with correct oral rest, posture, tongue up, lips closed, teeth apart, breathe through your nose. Let's get started. Robin, welcome back to the podcast.

Thank you for having me. It's a pleasure.

It's been a while, so, you know, I'm glad to, to circle back and of course we're going to be talking about some fun topics today.

Yeah.

So let's jump right on into it because I think that there is a little bit of a rise again in this whole EBP evidence based practice talk, you know, as it relates to myofunctional therapy. So while, you know, EBP is foundational, I think it's often misapplied and misunderstood. And so let's, let's start there.

Okay. So for a while it's been very quiet other than know social media that's always going to be there and people with their opinions and misinformation hotlines and things of that nature. But we have been through the Oral Motor Institute and just individual therapists. Up until last year, I felt like there was a five year streak where we weren't hearing or reading a lot of problems from like the evidence based groups on Facebook. A lot of our colleagues in the orofacial myology world were presenting at the annual ASHA convention. I was there. There was a topic on oral peripheral examinations and why they're important. You know, there was enough, there was a sprinkling. Is it enough to satisfy what I think should be there? You know, I've worked with ASHA on the practice portal for OMDs. We've been writing them for several years that we need our own topic area. But since last year's convention it's been very disappointing and I'm seeing a resurfacing of failure to accept research. In working with the head of the portal, which is Sarah, there were certain papers like my own paper with Dr. Baxter and looking at tongue tie and speech and feeding and sleep. And I was told, well, that's not strong enough evidence. I'm like, well, it's a 3A cohort study. What's wrong with this paper in being able to add to the portal that tongue tie can affect more than breastfeeding. And just yesterday I was getting like bombarded. I'm in a virtual session and I see my phone like going crazy. And there was a blog done about people selling out to pseudoscience and certifications. And of course, what was the first topic? Myofunctional therapy and talk tools. And I'm like, why are they bringing a company into this? We don't even have a certification product.

Yeah.

So you know, once one starts it up again, then it's like, oh, I can come out from under my rock and start, you know, picking on the myo people again. And it's very frustrating and disheartening because you see it, you know, every other profession wants to do it to the point where it's not really in, even in their scope of practice maybe to do it like I'm seeing singers doing myofunctional therapy and assistants doing myofunctional therapy and starting business and businesses. And then we have this gatekeeping of you can't treat sleep, you can't treat tmj, you can't treat, you can't diagnose the malocclusion, you can't say whether a tongue tie surgery needs to be done. It's like total gatekeeping. Mm.

Yeah. Yeah. It feels like, I don't know, 2020 all over again.

I feel like 2000, 2007, you know, when it started, when Watson and Loft wrote that article, that was not a systematic review. It was not an rct. It was a narrative review of literature that was completely biased on their opinion and they invented that term non speech oral motor exercise. It was never in the literature before.

Well, and I think it's important for people to even understand like what pseudoscience even is because I see that like term thrown, you know, around with this whole ensome discussion so often. And you know, it's like if you have a belief or a method or a practice that like claims to be scientific. Right. But it lacks the actual evidence, the actual research and true methodologies that are required in the scientific community. However, hi, we have all of that. We have the research, we have the evidence. Right. To back everything that we're doing in Mayo. And it's, it's almost mind boggling to me that we're still having this conversation because there are hundreds and hundreds of articles out there. And you know, even as, yes, more research needs to be done, I think we also, I'm constantly reminding people we have to even look beyond like the speech journals, they're not all in speech journals. Sometimes you have to look at related journals to find the information on all the topics that feed into the work that we do in myofunctional therapy as. So I'm sure you have a lot to add to that.

But look, we do need quality evidence, but every year Asha puts out this report of where we all are in the field, and most of us, believe it or not, are in the schools. And then it's sprinkles of who's in the hospital, who's in the clinic, who's in academia, or unless you're me and you work in all the settings just to be well rounded. The fact of the matter is we have like 1% of our field in research science.

Yeah.

And under 1% in doctoral school. And then you have to think about, you know, what do you need to get an IRB and do no harm to the patient. So when people say, well, what you have to do is like, take a group of kids that have a tongue tie in speech. And we actually brought this up in the paper that I did with Sharon Smart and her students over at Curtin University in Australia. We do this paper and we're studying, does OMT as a standalone therapy help speech? And it was a systematic review, and it came out that it didn't. But when we looked at the data and I had this aha moment looking at it, and I'm saying, but what these papers were doing that are in our systematic review, isn't speech related? A lot of the movements were not speech like movements. So I said, let's break this down and let's blindly. The clinicians in the group, myself, Sharon Smart, Danielle Carey, let's take a look at. Is it really myo. Was it traditional artich. Was it oral placement therapy? Was it a non speech or a motor exercise? And, you know, random. And we found that they were doing all of the above and for all different sounds. Right. So it's that homeogeneous group. How do you get the systematic review to say what you want it to say? And then, you know, the informed SLP got their hands on it and they twisted it and wrote like a review on it of like, yes, we knew it. OMT doesn't help speech. Wait a minute. Just wait a minute. Because that's not what the paper said. I know because I was the lead author on this paper. And what we found is that there were moderate quality studies that did show that OMT can help improve speech. But overall, it's not standalone. And we already know that.

Right.

You know, I'm not going into therapy taking off my speech hat and saying, oh, I'm only doing myofunctional therapy, and then I'll do the speech on a different day. It all goes together. And I do have patients that I Take on, they'll have a terrible list. I'll prep them for a frenectomy, I'll work on their post op neuromuscular reeducation, and their speech spontaneously approves, improves. But how do I get that into a study? Because you go to do an IRB and you want to say, hey, I'm going to take this control group and I know they're tongue tied and I know a frenectomy would probably help them, but I'm not going to send them for a consult for a frenectomy. I'm just going to keep doing speech therapy. But with the other group, I'm going to send them over to Dr. Siegel in the city and he's going to do the frenectomy and I'm going to use speech therapy, myofunctional therapy, and have the surgery under their belt. And who's going to approve that? That if we know, you know, this surgery can help the patient, especially in children.

Yeah, yeah, 100%.

It's very complicated because one, we don't have enough research experts to help conduct, you know, the type of study, these large RCTs, but then even when they exist, like, look at Dr. Gihari. He's done RCTs with breastfeeding infants and our world still doesn't want to accept them.

Yeah, well, and I think that, you know, a lot of, like, critics, if you want to call them that, right. Are lumping Mayo into this whole pseudoscience category simply due to the limited RCT level studies. Right. And I think it's just, it's a major misrepresentation because where MYO is built on anatomy and physiology, right? We've got our oral structures, our tongue posturing, our breathing, right? And then as therapists, we're constantly collecting data, we're tracking our outcomes and we're adjusting our plans based on real client responses, which I think is core to evidence based practice. But everybody seems to ignore that, right? And then you've got the clinical experience and client outcomes, which also equally counts as part of that EBP triangle, especially in areas where, like, large scale studies, you know, maybe aren't happening yet or maybe we'll catch up at some, you know, at some point. I don't know. So while I feel like the field obviously is still evolving and needs more public, published research, I think one of the biggest things that, like, has been one of my soapboxes over the years is like, we can't dismiss Mayo as pseudoscience because, you know, then we're ignoring the clinical relevance and the foundational principles that Mayo is built on.

And it's been around for 50 years, more than 50 years.

It's like 117 years, I think, technically, right, or, or something that they initially started talking about these exercises in Mayo and all of that.

And if you look at the Marshalle guide and I always say this, semantics matter and part of the problem is if you're not doing this every day, you don't know how to differentiate non speech oral motor exercise from an orofacial malfunctional therapy exercise, from an oral placement exercise from myofascial release. And it's even the patients that call, I have a baby, I need myofunctional therapy or I need to go for a tongue tie release and I'm looking for a myofascial therapist. All of this jargon. The professionals don't know the right terminology. The patients are not going to know what to look for. And this is my 32nd year in the field and I've watched fads come and go. Like when I first started in the mid-90s, it was when childhood apraxia of speech was new and everybody thought every kid had apraxia. And then come 2000, it was prompt, prompt, prompt, prompt. Everyone wanted prompt certification. Parents wouldn't even step foot in the door of your practice if you didn't know how to do prompt. And then the oral motor was huge. You know, from about 1996, 97 till 2007, it had a good 10 year run that everyone was seeking oral motor therapy. And myofunctional therapy was there, but it was more in relation to orthodontics. So it wasn't as prevalent as this concept of airway orthodontia and proper breathing and resting posture mainstreamed into the public. This article that came out yesterday, you know, they were lumping OMT in with, I believe, Linda Mood Bell and, or in and reading programs. And it's like, what? I mean, whole school districts are trained in these methods. And to say there's no research. There's the entire International Journal of Orofacial Myology and myofunctional Therapy. And when this gets thrown at me, I'm always like, here's my 50. You know, it started as a 36 page compendium and now I think it's up to like 56 pages. And it's all, you know, level one through five research. All of it matters, as you said. And this constant pushback, it's like, why doesn't Asha want an OMD category at convention, because every other practice portal has a parallel representation. And I was told, well, we would then be changing the construct of the convention to feature a certain type of therapy. I'm like, do you not understand that orofacial myofunctional disorder is a diagnosis? It may not have an ICD code that we can bill for. There's an ICD code, and it used to work, but when every profession started using it, it got flagged and they stopped paying for it. But we still code an OMD under dysphagia and organic speech sound disorder or other speech sound disorder. And the root of this is we're not trying to change that. Traditional therapy methods for articulation work for a certain group of patients or students that have functional or idiopathic basis developmental delay. Unknown reason. We're talking about a subset of individuals that has a disorder that both form and function are affected. And I try to really help my graduate students that I teach at Brescia understand this. But more importantly, we need our own field to understand this, because everything loops back to traditional therapy. ASHA has that speech sound map, and it shows there's developmental, functional, and there's organic. And one of the reviewers. And we could take a deeper dive into this if you would like, but one of the reviewers from my ASHA proposal on speech and OMDs made a comment that, well, what kind of motor speech disorder are you talking about that's organic? Are you talking about dysarthria or apraxia? It's like, no, I'm talking about a structurally based speech sound disorder, which is in the ASHA map. If you don't know that, you shouldn't be reading people's proposals. And this is why the OMI keeps fighting for this. I'll say it time and time again. If you had me read something on fluency, I wouldn't be able to judge if it's good or not. Yeah, that's not my area of expertise. And if you gave me something to read on, like speech science, I wouldn't be able to do that either. So you have people reading proposals that don't know that in the speech sound disorder map, according to asha, structural anomalies and craniofacial issues. And that's the thing. You submit it to craniofacial, they bounce it to ssd. You submit it to ssd. I didn't submit to ssd. I submitted to motor speech. And they moved it.

Yeah. Yeah. ASHA doesn't seem to like to change, um, how they do things. And I've I've noticed that in the past like year or two, just on, even outside of the MYO space, there was just a lot of pushback to any change to any. This is how we do things here. And this would disrupt how we do things if we were to make such changes. And it just seems to be like the mo. Like that just seems to be their, you know, their modem operandis right now. They're just kind of like, no, we don't want to, you know, veer off from what we're doing. But to your point, I also think what people need to know is that sometimes people are friends with other people. Sometimes these people get invited onto review committees that don't actually belong on review committees because to your point, they don't have the expertise to be reviewing submissions. And then they get to just decide that Mayo isn't going to have absolutely zero presence at ASHA this year. Which is exactly what's happening. Right?

Two years in a row and two years in row. And I agree with this because first Ash just said, we are going to get some SMEs on these committees. Who would you recommend? And we had a whole list. And then they came back and said, yeah, nah, they don't want you on the committee. Like we can't force them to put you on the committee. And I'm like, okay, let's see what happens with the proposals. Then the proposals go in and they bounce them around where we don't want them and specifically put them in motor speech because we knew that there were committee members that are very publicly anti myo making fun of people using two sets or denouncing tools and feeding therapy or sitting at their computer going, me trying to avoid the tongue tied posts with audio and all of this stuff. And you know, Asha tells us, hey, here's a code of how we should behave on social media. And then doesn't hold their members accountable to it and then has them judging other the very people that they're poking fun at. Of course, what ended up happening is they all got rejected. I don't, you know, know if people want me mentioning their names, but there was a proposal on lateral bracing for R and I believe snz, that was actually a dissertation, an approved dissertation. Not accepted.

Wow.

Baby lead weaning update using a sensory motor approach.

Reject pediatric feeding. I mean this is like ridiculous, right?

Then we have a dive into the data on our systematic review. A published systematic review, Highest level of evidence, level one evidence. Reject it. For five years in a row I've been submitting on tongue tie and speech. They kept telling me I was biased. So I brought in Danielle and Sharon to help me with the proposal to make sure that it was neutral and that I was showing that there is controversy in the literature. And let's break down the data. I was told that I was too neutral and. And that the literature review is weak because I didn't describe the type of evidence. It's like in four case studies, in a cohort study, in an rct, in a systematic review. So, you know, I'm appealing these things. And I'm told, well, sorry, Robin, you can't appeal that unless there's a technical error. I'm like, the reader is saying that there's something missing from my paper that's blatantly there, that's not technical. And my favorite of all of them was. This proposal did not thoroughly describe what the diamond MYO technique is. And I had to think about it. I go, that's the name of my practice. They literally confuse the name of the practice on my bio with the submission. So here's the thing. Why is a journal blind? Peer review. But the ASHA convention is, what my colleague pointed out is single peer review, meaning they can see who we are, but when we get their reviews, we're not allowed to know who they are.

That sounds very on par with how Asha does things.

So it really doesn't make any sense because as soon as, for example, last year, I purposely submitted under my own practice name because if people see anything, talk tools, myo, omi, iao, anything like that, there could be a bias. I was told I wasn't accepted because I have bias because I work for talk tools. But yet at Asha, there were other people. Like, no offense to dawn, but she's easy peasy, and she presented and had a table at Asha. Why is it okay for her to present? And she has products. I don't even make money off cups, drawers, any of that. I only make money and always disclose off of tools or products that I've created, mainly textbooks.

Yeah, but Robin, it's not even you that's getting denied, right? I mean, I know I've got friends and colleagues who submitted on different breathing, myo, airway, you know, all these different topics and not one presentation was accepted. They maybe they have private practices, but they haven't written anything. They don't have courses, they don't have things to sell. Right? They're just there to educate like they do their families and their patients. And they want to educate other SLPs and they're not accepted either. So I just. It's, it's very obvious. It's.

They're reaching, it's excuses and it's critical because we know the real reason isn't that that I'm a consultant for Talk Tools. It's the topic and they're just pulling at straws. And that's why I demanded it be submitted as a technical appeal, because clearly they didn't read the proposal that I put in at 1. One of the reviewers also said this is too close to the systematic review by Merkel Walsh. Hello. I'm the person submitting it and I'm the person who wrote the paper. And we disclosed that in the systematic review by blah, blah, blah, blah, blah, we found this and we want to take a deep dive into the data to gain a deeper understanding of what this means to us clinically. Because what we didn't want that paper to do is Gaslight clinicians that we know and we understand that OMDs affect speech, we know that, but how do we set up the right study? So we were going to propose different study designs and where to move forward, but that got squashed as well. So how are we going to do the research that they demand? Research starts in the clinic and then you get to case study, case series, cohort study, rct, systematic review. How are we going to get there if Asha doesn't practice what they preach and hear what we have to say? Linda d' Onofrio and I too, they had this like, global, you know, new innovative things. And we wrote about how SLPs all over the world are treating it with myofunctional therapy and what this means for us here and why it's important. And in teaching a graduate level course and having to do a lot of research for it, sleep and MYO really has the most empirical evidence. It's breastfeeding and tongue tie and it's sleep and OMT. That's where the strongest RCTs and systematic reviews are. So if Asha's not going to accept that and people are moving on without them fix, SLP is finding all these problems and people are going to their state licensure and apta. They don't pigeonhole their therapists the way Asha does to us. You can't do this. You can't do that. Well, I even told them you're saying that we can't use OMT to treat sleep, but PT and OT are doing it. Why? Yeah, why? You know, we're here and I have nothing against otpt, but they have so many Modalities to work with and in. And the mouth was always our territory, and now others are stepping in because our field, a lot of therapists are afraid to do it. They're afraid to be, you know, scrutinized. You have to have a strong backbone and a thick skin to really, you know, shine above when all of this noise and ridicule is constantly going on.

Yeah, yeah. No, we have a lot of therapists, speech pathologists, who will come in and, you know, they're newer to Mayo and they're like, I had no idea the pushback I was going to get by simply trying to help my patients. And I'm like, welcome to the world of Mayo. And this nice little split between speech pathologists who just don't seem to believe in it, which makes absolutely no sense, because if we believe that we have muscles in our body, you know, hi, we use them.

Right.

So there's that. But I know, also with the Practice Portal on Asha's website, haven't there been some changes or things made to the Practice Portal as well without the knowledge, unbeknownst to some of the peoples whose names live on that webpage?

Yes. So I have been writing Asha since 2018, because when the portal was originally, they put together a team. Mary Billings was involved, Honor Franklin, Bob Mason, Sandra Holtzman, to name a few. Pat Taylor. And Mary put her own team together to help her do the research. So it was myself, Nicole Archambault, Christy Gatto and Linda D'. Onofrio. And we sent in like a 50 something page information, and they took some from us and some from everybody. And it wasn't perfect, but we were pretty happy with it. And over the years I would write them. I really think you should change the tongue tie section. It sounds really unprofessional about clipping the tongue because they hang on to everything that Dr. Kummer says about tongue tie and no one else. And I got them to change it, which was a miracle to at least have it say, there's emergent research beyond the breast and here's some new RCTs. And while SLPs don't decide on the surgery, they're a very important part in determining medical necessity and functional implications of Tetradoral tissue. Beautiful. Well, I get an email from a very lovely therapist that says, you know, I was asked to write, you know, this portal help with revisions. And I just thought that, you know, we were updating and adding the research, and I come to find that there's another author that is not a subject matter. Expert in OMDs. In fact, they often go on social media and be rape therapists that do any type of oral motor work. And the portal was really not reading well. It really dummied down a lot of what we do. It took out all the resistance and strengthening exercises. It took out the oral placement component and basically demoted us to people who work on tongue resting, posture. With a lot of effort and back and forth. I was able to update a lot of it, get some of it restored. They didn't agree on all of it, but I'm now listed as someone who helped update it. And my argument was I'd like to see the non apraxia experts on the apraxia portal and I want to see the language people on the feeding portal and same people that are judging Asha Asha submissions. And it's nothing personal, but I just don't understand it. And then, you know, there's been some recent posts like who me? I don't hate mayo or give me the doi. I need to read the study. I'm like, I'm giving you 53 pages of research. Enjoy.

Yeah.

Because any doi anytime I've tried to give research, it's never good enough. It's, you know, and this. Look, I don't have a PhD and I've written research. You don't necessarily need a PhD to understand or write a good paper. But when you're judging PhDs and other people that have been in the field much longer than you or have, you know, been discussing this or publishing on this or involved in this for a very long time, I find it to be very disrespectful. Like I always looked up to my professors, to my mentors. I don't understand it. And you know, you have to be able to move it, to use it. And this concept that people can just compensate with malocclusion or high narrow palates or oral restrictions doesn't make any scientific sense. We're in a field to help people remediate and overcome their disorder. No PT would teach a person to limp for the rest of their life. So why should we teach compensatory placements or mouth breathing? Because you can't breathe through your nose. It doesn't make any scientific sense.

I'm with you on that because I think one of these individuals who likes to be very anti tongue tie, anti mayo, and also seems to sit on many of these committees making decisions, but doesn't have the skill set to do so, is very big on teaching compensations and has even gone on their social media platform and basically saying, like, we should be teaching compensations. And I'm over here thinking, like in skilled therapeutic work, feeding speech, Mayo, whatever. Our goal is functional, like restoration. Like, we are not trying to teach workaround habits to make things look good and bypass the real issue. Right. We're trying to figure out what compensations are happening because ultimately over time that's going to break down further. And let's not teach compensations. Let's fix the root issue here. Right?

So ologists, we're supposed to get to the bottom of the problem and then establish a inter professional, multidisciplinary team to help the patient or the student. There goes the lack of understanding of not knowing that soft tissue always trumps heart. So if you teach all these muscular compensations, you're going to further agitate disharmony in the orofacial structures.

Yeah, yeah, yeah.

I mean, it's some things I've seen. Tongue thrusting is normal till 14. It's never normal. Not even a baby. The protrusion retraction that an infant uses to suck at the breast or bottle teeth is not a tongue thrust past the lip. And it's a balanced muscle action between the protrusion and the retraction, not a forceful protrusion with a snapback or rebound factor on the tongue retraction.

Yeah, yeah. And I think, and thank you for explaining that because I think people don't get that they, you know, even in teaching peed feeding, I get this all the time. The question comes through, well, well, at what age should we be eliminating those hung thrusts of the baby's feeding with. I'm like, it's not a tongue thrust. So thank you for highlighting that. And I just, I like to teach, and I like to highlight that teaching these compensations just reinforce, reinforces dysfunctional neuromodor pathways. Right. It's. We can't do the true neuromuscular reeducation that we talk about doing and the coordination aspect of it if we're just teaching or allowing compensations to continue. Right. And, and I, and I mentioned this, you know, briefly, but it worsens symptoms long term. Like we are going to have fatigue, we're going to have jaw tension, articulation arguably is going to worsen or not improve continued mouth breathing. I mean, the list goes on. Right? We're going to see all of these things just continue or worsen if we don't address the compensations. And then, hi, we talk about teaching carryover and generalizing therapy skills to real life. How do you do that? If you're teaching compensations, it doesn't.

Yeah.

Like, would you train for a marathon by letting somebody limp along? Like, that's not something else is going to break down? It makes no sense that.

Look, I have a vocal Polyp. Okay. Not 100% sure when it happened, but apparently at some point, I had a hemorrhage. I have autoimmune disease. So I have very dry mouth issues with, you know, my salivary ducts. And I was going through the end of my vocology program with a very severe upper respiratory infection. I had to sing and do things for my homework and my assignments. And at some point in that time frame, I hemorrhaged and I developed this problem. So does my voice therapist teach me? You know what I think we'll do? We'll teach you how to use your ventricular vocal folds. You can compensate. That would be horrible, right? Or you know what? We'll just put you in an all com device. You could just, you know, see your patients with some proloquo because, you know, that's a compensation. Like, no, I want her to help me get my voice back. And I know what to do. I just went to school for vocology, but I still need a therapist to guide me and to keep me on track. Yeah. Not to change the subject, because I think that was a great talk and I think we covered a lot. But another thing that never sits well with me. What do therapists have against using tools? Why is this such a point of contention? Like, they have no problem using a mirror or a tongue depressor, but if someone manufactured something that can help shape an articulatory placement, it's like the worst thing that ever happened in the field of speech pathology.

Yeah. No, and I see this, too. And we. I love tools. So, first of all, I think tools have a really important place for children whose nervous systems aren't ready to introduce food, like thinking, feeding therapy, or even myotherapy with kids who may have some aversions or other things going on until a child feels safe. You're not going to see me or my team bringing food into a session outside of maybe giving the kid a snack. Right. That it's not therapeutic. It's. You know, maybe we make it therapeutic at some point. But, you know, I hear people say things like, well, tools can become a crutch. Not if you're actually using them to teach a skill and then phasing them out. Right. Like, people. Some therapists I know have said to me things like, well, it encourages Compensatory behavior instead of true motor learning. No, it doesn't. Not if you know how to use it properly and you have, like, an end goal in mind. And, you know, I've heard people say, like, well, it shifts your focus away from, like, you know, them developing this, like, internal awareness and neuromuscular control. No, actually it doesn't. It builds awareness and it builds neuromuscular control. Yeah.

And, yeah, there's safety issues, there's shaping. And again, going into otpt, I worked for several years in the same room with an OT at my school. And one day she was doing handwriting without tears, and she had putty and like these little clothes pinned. She take them in and out. And I looked at her, I go, diana, what are you doing? And she goes, you know what I'm doing. No, no, no. I want you to talk me through what you're doing. And she's like, well, in order to hold a pencil correctly, you need to a pincer grasp. And you need the strength and dissociation, the wrist, the fingers. And that's a task analysis. Lori Overland taught me many years ago, 30 years ago, task analysis of function. So OTs breakdown, task analysis. PTs break down task analysis. Even in singing, when we're doing vocology habilitation, we task analyze. And interestingly enough, there's a lot of tools in voice therapy. There's a lot of oral motor in voice therapy because you're shaping the mouth to control the resonance, and you're working with breath, you're working with the vibratory source, you're working with the articulators and the resonators, and no one blinks an eye about it. Doesn't bother anyone. But yet in speech, like a still voice program is so closely related to myo, and that's what sparked my interest in this, in doing some research with Dr. Zagi, crossing over as the myofunctional vocalogist. It's a lot of fun, but you bring a tool in and it's like you're unethical or. I use tools every day. I know how to use them well. I shape sensory motor responses into the desired motor execution plan that I'm seeking or the motor planning that I'm seeking. And you know, there are a lot of newer therapists that go on social media. They'll use my exercises, other exercises, and they demonstrate them incorrectly or they're not using a tool incorrectly. I will drop them an inbox. I don't embarrass them. I drop them an inbox and Say, you know, would you be open to some advice? And you know, what you're doing was developed by so and so or it's developed by me and that's not the way you do it. Your patients showing A, B and C. And it's really not cool to teach someone else's exercise on the Internet without their permission.

Yeah, it's very interesting, this whole shift in the Internet. One of my friends and colleagues talk about this a lot and she and I feel very strongly like you will never see on our social media accounts us demonstrating prescribed exercises because I don't think that's appropriate. Not everybody needs the same thing. It's not going to look the same on everybody. And to your point, it's very interesting because a lot of clinicians looking to grow their accounts will do this and it gets them a lot of attention. But half the time I'm behind the scenes commenting with a friend or colleague going like they're not doing this right or there's a lot of compensation. Did you see all the compensations on that person's face? Like, this is awful. Like if we're going to educate, we need to do it properly. But also can we not do therapy on the Internet? And basically because then everybody, to your point earlier, thinks that they can do what we do, which they have no idea what goes into this.

Yes. And then the naysayers come in and make fun of it because they don't know what they're looking at. Or you're like, oh, that person put this exercise up and it's not correct. And now you're opening the door, adding.

Fuel to the fire. Yep.

And that's not right either. You know, even if they're doing it wrong, that doesn't give anybody the right to put it publicly. Ridicule.

Right.

But the only time I've ever put an exercise up is in my own voice journey. I've been doing little clip. Its like here I am doing my voice homework, you know, when the therapist becomes the patient and sharing a little bit of my journey of what it's like being a speech pathologist and you know, dealing with vocal strain and hoarseness and how do I do pacing and I work 12, 13 hours a day and I do things like this which are really important to me. But when do I get to rest my voice and what do I do throughout the day to keep my stamina going. But with a patient, this is myself. I'm sharing my own journey. I don't know. I teach courses. If people want to learn how to do the exercises correctly, you go to the course so that you can see videos and demonstrations of this is what the right way looks like and this is what the wrong way looks like.

Yeah, no, absolutely. And I mean, and I'm with you and kind of going back to that whole tool discussion because I think the tools sometimes are an easy, an easy thing people think to like show in a demonstration for a social media post. I still love, you know, I love tools. I. I'm a big proponent of them. Like I was saying, you know, I think that just to speak to what we were touching on before, you mentioned like a sensory motor, you know, component, they create immediate sensory feedback. And I think that some of the tools that are out there, you know, that tactile input, the visual input, they get that proprioceptive feedback, it really helps the clients understand and feel what we're asking them to do. Especially in children where maybe we can't have the conversation, you know, it's. They don't have the cognitive ability yet to fully grasp what we're doing. So we're teaching them in other ways. We're using all of their senses. Right. And it's like, oh, that's what you want me to do? Okay, got it. Right. I think I've seen, you know, lots of clients break through motor planning blocks. Like, it's sort of a bridge, if you will, from like, they really can't do it to like, we're doing it with little help. And once they can do it independently, we're going to fa, you know, we're going to start to phase this out with the scaffolding. And you know, you were talking about the different hierarchies and task analysis and everything that I think so many people, they don't stop and think. They don't think about, like, this is how we do therapy. And this is really, it's not a crutch. It is a teaching tool.

Right. And that's where that breakdown when I wrote the 2020 paper on OMDs in zero to four and children with special needs, like, if you truly want to understand orofacial myology, you have to understand normal and what happens at zero to three. And this therapy has existed for decades. Like in Pam's book, I have it. Oh, I don't. It's actually at home when you look at that book. When we were elocutionists, this was even being discussed, you know, over 100 years ago. And it upsets me that people try to rebrand this as like mini Myo, baby myo. I'm not saying that you don't work on oral motor skills with the population, but it's already been long established as pre feeding, oral motor sensory, oral motor feeding therapy. And that's when the tools are really important. But guess what? I work with elementary school kids at school, I work with tweens, middle schoolers, high schoolers and adults here in my office. And I use the scentsy, I use horns, I use straws, I use bubbles. Because even in a population the magic.

Isn'T in the tool. Right? It's not in the object. It's basically what is your goal, what's your intention behind using using it, what is your skill level? But how have you learned how to use it? Do you know how to let's be talked about before compensations and make sure that you're actually supporting the patient and not furthering the compensation. You know, transitory patterns that they're using. Right. Like what is your clinical insight around this? And I think that whole critical thinking thing is so lost these days. Like if you don't talk about how feeding and myo it's such a dance between art and science.

And that's a perfect example.

You know, we have a lot of evidence that these tools work and when used for properly, they're very supportive to our patients and to our end goals.

Actually do what the tongue needs to do and then fading out that bite block so that the patient can do it independently. But if you don't know that and you're not trained in that and you look at it on a social media post, you're like, what are these people doing? When I see something that I don't understand, like there's been use now of red light therapy and you know, some clinicians are even, even looking into can oralase be part of our scope of practice because it's not cutting anything. And some of the state licensure boards are coming up with, we find, you know, it's another tool. You know, if you're not doing surgery, if you're using something and you're trained in it, speech pathologists can go for ndt, they can go for myofascial release, they could go for craniosacral therapy. And these are other methodologies. And it's really important to understand in the world of oral motor disorders, it's not just about orofacial malfunctional therapy. That's one modality that helps an OMD and it occurs across the lifespan. And there's a lot of different techniques and tools that we need in our Repertoire. Because all the patients are different.

Yeah, no, and I see this too, and we. I love tools. So, first of all, I think tools have a really important place for children whose nervous systems aren't ready to introduce food. If, like making feeding therapy or even myotherapy with kids who may have some aversions or other things going on. Until a child feels safe, you're not going to see me or my team bringing food into a session outside of maybe giving the kid a snack.

Right.

That it's not therapeutic. It's, you know, maybe we make it therapeutic at some point. But, you know, I hear people say things like, well, tools can become a crutch. Not if you're actually using them to teach a skill and then phasing them out. Right. Like people. Some therapists I know have said to me things like, well, it encourages compensatory behavior instead of true motor learning. No, it doesn't. Not if you know how to use it properly and you have, like, an end goal in mind. And, you know, I've heard people say, like, well, it shifts your, your focus away from, like, you know, them developing this, like, internal awareness and neuromuscular control. No, actually it doesn't. It builds awareness and it builds neuromuscular control. Yeah.

And, yeah, there's safety issues, there's shaping. And again, going into otpt, I worked for several years in the same room with an OT at my school. School, and one day she was doing handwriting without tears, and she had putty and like these little clothes, pinch, taking them in and out. And I looked at her, I go, diana, what are you doing? And she goes, you know what I'm doing. No, no, no. I want you to talk me through what you're doing. And she's like, well, in order to hold a pencil correctly, you need a pin, a pincer grasp, and you need the strength and dissociation the wrist, the fingers, and that's a task analysis. Lori Overland taught me many years ago, 30 years ago, task analysis of function. So OTs, breakdown, task analysis, PTs, breakdown, task analysis. Even in singing, when we're doing vocology habilitation, we task analyze. And interestingly enough, there's a lot of tools in voice therapy. There's a lot of oral motor in voice therapy because you're shaping the mouth to control the resonance, and you're working with breath, you're working with the vibratory source, you're working with the articulators and the resonators, and no one blinks an eye about it. Doesn't bother anyone. But yet in speech, like a still voice program is so closely related to Mayo. And that's what sparked my interest in this, in doing some research with Dr. Zagi. So, you know, in, in crossing over, you know, as a myofunctional vocologist, it's a lot of fun. But you bring a tool in and it's like your unethical or I use tools every day. I know how to use them well. I shape sensory motor responses into the desired motor execution plan that I'm seeking or the motor planning that I'm seeking. And you know, there are a lot of newer therapists that go on social media. They'll use my exercises, other exercises, and they demonstrate them incorrectly or they're not using a tool incorrectly. I will drop them an inbox. I don't embarrass them. I drop them an inbox and say, you know, would you be open to some advice? And you know, what you're doing was developed by so and so, or it's developed by me and that's not the way you do it. Your patients showing A, B and C. And it's really not cool to teach someone else's exercise on the Internet without their permission.

Yeah, it's very interesting. This whole shift in the Internet. I, you know, one of my friends and colleagues talk about this a lot and she and I feel very strongly like you will never see on our social media accounts us demonstrating like prescribed exercises because, you know, I don't think that's appropriate. Not everybody needs the same thing. It's not going to look the same on everybody. And to your point, it's very interesting because a lot of clinicians looking to grow their accounts will do this and it gets them a lot of attention. But half the time I'm behind the scenes commenting with a friend or colleague going like, they're not doing this right. Or there's a lot of compensation. Did you see all the compensations on that person's face? Like, this is awful. Like, if we're going to educate, we need to do it properly. But also, can we not do therapy on the Internet? And basically, because then everybody, to your point earlier, thinks that they can do what we do, which they have no idea what goes into this. Yes.

And then the naysayers come in and make fun of it because they don't know what they're looking at. Or you're like, oh, that person put this exercise up and it's not correct. And now you're opening the door for adding fuel.

Yeah.

And that's not right either. You know, even if they're doing it wrong, that doesn't give anybody the right to publicly ridicule. But the only time I've ever put an exercise up is in my own voice journey. I've been doing little clip. It's like here I am doing my voice homework, you know, when the therapist becomes the patient and sharing a little bit of my journey of what it's like being a speech pathologist and you know, dealing with vocal strain and hoarseness and how do I do pacing and you know, I work 12, 13 hours a day and I do things like this, which are really important to me. But when do I get to rest my voice and, and what do I do throughout the day to keep my stamina going? But with a patient, this is myself. I'm sharing my own journey. I don't. No, I teach courses if people want to learn how to do the exercises correctly. You go to the course so that you can see videos and demonstrations of this is what the right way looks like and this is what the wrong way looks like.

Yeah, no, absolutely. And I mean, and I'm with you and kind of going back to that whole tool discussion because I think the tools sometimes are an easy thing people think to like show in a demonstration for a social media media posts. I still love, you know, I love tools. I, I'm a big proponent of them. Like I was saying, you know, I think that just to speak to what we were touching on before you mentioned, like the sensory motor, you know, component, they create immediate sensory feedback. And I think that some of the tools that are out there, you know, that tactile input, the visual input, they get that proprioceptive feedback. It really helps the clients understand and feel what we're asking them to do. Especially in, in children where maybe we can, they can't have the conversation. You know, they don't have the cognitive ability yet to fully grasp what we're doing. So we're teaching them in other ways. We're using all of their senses, right? And it's like, oh, that's what you want me to do? Okay, got it right. I think I've seen, you know, lots of clients break through motor planning blocks. Like it's sort of a bridge, if you will, from like, they really can't do it to like we're doing it with a little help. And once they can do it independently, we're going to fate, you know, we're going to start to phase this out with the scaffolding and you know, you Were talking about the different hierarchies and task analysis and everything that I think so many people, they don't stop and think. They don't think about like this is how we do therapy. And this is really, it's not a crutch, it is a teaching tool.

Right. And that's where that breakdown when I wrote the 2020 paper on OMDs in 0 to 4 and children with special needs, like if you truly want to understand orofacial myology, you have to understand normal and what happens at zero to three. And this therapy has existed for decades, like in Pam's book, I have it. Oh, I don't. It's actually at home. When you look at that book when we were elocutionists, this was even being discussed over 100 years ago. And it upsets me that people try to rebrand this as like mini myo, baby myo. I'm not saying that you don't work on oral motor skills with the population, but it's already been long established as pre feeding oral motors, sensory oral motor feeding therapy. And that's when you know the tools are really important. But guess what? I work with elementary school kids at school, I work with tweens, middle schoolers, high schoolers and adults here in my office. And I use the scentsy, I use horns, I use straws, I use bubbles. Because even in adult populations, those techniques are still the foundation. There is a lot of inattention to dissociation and grading of the muscles. And that's where my foundation came from. From Sarah Rosenfeld Johnson, from Char Boshard and from Lori Overland that were very good about teaching. If you don't have the dissociation, the exercise is not being done right. And that's a perfect example of where a tool comes in. Using a bite block to stabilize the jaw so that the tongue can actually do what the tongue needs to do and then fading out that bite block so that the patient can do it independently. But if you don't know that and you're not trained in that and you look at it on a social media post, you're like, what are these people doing? When I see something that I don't understand, like there's been use now of red light therapy and you know, some clinicians are even, even looking into can oral lace be part of our scope of practice? Because it's not cutting anything and some of the state licensure boards are coming up with, we find, you know, it's another tool, you know, if you're not doing surgery, if you're using something and you're trained in it. Speech pathologist can go for ndt, they can go for myofascial release, they could go for craniosacral therapy. These are other methodologies. And it's really important to understand. In the world of oral motor disorders, it's not just about oral facial malfunctional therapy. That's one modality that helps an omd, and it occurs across the lifespan. And there's a lot of different techniques and tools that we need in our repertoire because all the patients are different.

Yeah, well, and I think it's like the magic isn't in the tool. Right. It's not in the object. It's basically what is your goal? What's your intention behind using it? What is your skill level? Have you learned how to use this? Do you know how to, like we talked about before, look for compensations and make sure that you're actually supporting the patient and not furthering the compensation, you know, compensatory patterns that they're using.

Right.

Like what is your clinical insight around this? And I think that whole critical thinking thing is so lost these days. Like it's, we talk about how feeding and myo. It's such a dance between art and science. But there's, you know, we have a lot of evidence that these tools work and when used properly, they're very supportive to our patients and to our end goals.

And it's not one study. This, this is what drives me crazy. Give me this study on the horn. No, the, the science comes behind comes from knowing about respiration, knowing about phonation, knowing about vibration of the vocal folds, knowing phonetic placements. Like you have to put all of that science together because it's not about one muscle, it's not about one motor plan, it's not about one skill. If I hear one more time, there's different nerves that innervate for speech and feeding. We know this, but they're the same muscles. So why do football players go to ballet class? To get grace to use the muscles in a different way to help with their agility. It's exercise physiology and muscle science.

So.

You know, I think that, you know, we talked about so much and it really, it really just circles back, you know, to. I don't even like the evidence based triangle anymore. I like the circles that interact or the diamond in looking at external and internal evidence as equal. But I never turn away. Someone, you know, invites me to work on a research project. I do the best I can to drive the field forward and Help all of us that do this work so that, you know, we don't have to be bullied all the time. Yeah.

Well, thank you. I know we covered a lot today between Asha and, you know, pseudoscience and tools and all the things, but I think it's an important conversation to continue to have because again, like you said, this whole conversation has resurfaced and we can largely thank social media and some common naysayers in our field for this. But I think it's really important because we get, I get a lot of newer clinicians, as I'm sure you do too, coming to me going like, wait, I thought these things were helpful. And wait, I thought, you know, I'm hearing this, but now I'm seeing this online and, you know, I think for those of you who are confused and you're seeing two different conversations, like, stop and think. Right. Think about what we've talked about today. Think about what makes the most sense to you. Because as a speech pathologist, my goal at least is to help my patients and to and root cause medicine. What is the root cause? If we can uproot what's happening, that's going to enhance, you know, alleviate a lot of the signs and symptoms. If we're going to keep taking this whole band aid approach to treating signs and symptoms directly, you're not going to get anywhere and you're going to have those patients that just keep coming back and coming back and coming back. And so just kind of a little PSA to, you know, like I said, stop. Think what actually makes sense, what seems functional. How do we give patients, you know, how do we give them function? How do we bring them back to function? Should be the biggest question.

Remediation over compensation. Always.

All day, every day. Yes. Well, thank you, Robin, so much. Remind everybody where they can find you.

Of course. So on Instagram and Facebook, we have the Oral Motor Institute. And that page is growing slowly but surely. A lot of good content, a lot of breaking down research studies and using a little humor as well. And then my Instagram it personally for my practice is the myofunctional vocalist and I'm here in Richfield and still consulting for Talk tools and really simple. My email is Robin Merkel, walshmail.com Amazing.

Well, it's always a pleasure to have you on. I know it's been a while, but I love talking about these topics. So thank you for coming on and sharing all this with us.

Thank you for having me again and always helping to drive the field. Thank you forward.

Of course.

Thank you.

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