Episode 289: Assessing & Treating Myo with Hallie Bulkin, MA CCC-SLP, CMT®, CPFT™

Hello friends, and welcome to episode 289 of Untethered Podcast. This is your host, Hallie Balkan and I am excited because we're actually opening doors super soon. October 21st through 25th, we'll be opening doors to the mile membership. So go to the myomembership.com Add yourself to the wait list. But before we jump in today, I want to just state that if you haven't listened to the last episode on on screening for myofunctional Disorders, I highly recommend you take a listen because we went over some key things to be looking for and that's gonna really help you out today. All right, let's dive in. Quick disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the unt. Welcome back to another 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, tetradural 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, heart breathe through your nose. Let's get started. Okay, friends, so as I mentioned, doors to the My Membership are opening October 21st through 25th. Get on the wait list at the Myome membership.com For now, I want to go over some key things when it comes to assessing and treating mayo and really orofacial myofunctional disorders. OMDs. So when I say myo or OMD, you know what I mean? Okay. I'm using it interchangeably now, just like any other therapeutic assessment or intervention, we're going to want to take a case history, right? You're going to have an intake form that asks certain things. But what I like to do is I really like to spend time deconstructing that MYO evaluation, that orofacial myofunctional evaluation. And here's the cool thing, right? This is something I teach in a couple of places. I teach it both inside the Mayo Membership. It was the very first training that still is a fantastic training. It's available from July 2020, when we first launched the Myo membership. So you can go back and watch that if you join the membership, if you end up enrolling in the MYO method, like the full MYO course that I offer, it's in there as well. But I wanted to just share that so you can, like, deep dive into this topic if that's what you desire. Because I really think it's important to, like, break things down. And before we can do that, I think we need to review, like, the goals of Mayo. What are we even doing in Mayo? What are we looking for? Well, we know we want to correct oral rest, posture, oral prep phase, oral phase, swallow, while eliminating things like drooling or oral noxious habits. Right. When we're putting things in our mouth that are not food items, whether that could be thumb sucking, nail biting, chewing on pencils, anything that's happening frequently with great intensity for, you know, a duration of time, tongue thrusts, tongue forward rest posture, or tongue forward posture, you know, during swallowing, open mouth posture, mouth breathing. Right. These are some of the things that we're working on when it comes to myo. And so when I say correct oral rest posture, what do I even mean? I mean tongue up, lips closed, teeth apart, breathe through your nose. Okay? That's our little. Our little phrase we say. And I'm really excited because we have a big surprise coming soon, something I've been working on with, with a colleague of mine for a long time. And so stay tuned because we have an announcement that will hopefully be coming. I think I announced it maybe like a year ago. And then we just hit pause again. I'm not kidding when I say we've been trying to get this out to the world for like, four years, because we started, I think, when she was pregnant with her youngest and he is now 4. So anyways, stay tuned for that. Okay, so when I say teeth apart, what do I mean by that? There's an argument in the MYO space that teeth should maybe be together gently together or slightly apart. I was taught that teeth should be slightly apart. There should be this, like, freeway space is what they called it in my initial course I took where you have like, between 2 to 3 millimeters between the teeth posteriorly between, like, your molars, and then about 4 to 6 millimeters anteriorly, you know, between your incisors. If you're not sure what those teeth are, go Google it. It'll show you an image. Easiest way to understand. So what do we do? Right. If we've done a fast MYO screener like I talked about in the last episode, we look at some of those findings to carry it forward to see, like, what do we want to dive into when it comes to this individual patient? Because while we may give you, like in my course and, you know, everything, we may give you an assessment form, a checklist, sample reports, a template to use to write reports, like literally everything you need, you still need to understand why you're doing what you're doing to make sure it truly is individualized and to make sure you're collecting the right information. So the case history is really important. You know, we give you a comprehensive intake form and you're welcome to use it. It really helps you kind of like gather the information you need upfront, prepare your evaluation so that you know what to look for. In regards to MYO airway tots, are there questions that you need answered based on some of the information that was or wasn't provided on that intake and the case history portion of that intake? Right. And one of the biggest tips that I can't believe I'm giving away for free on the podcast because it seems so simple, but it's so mind blowing to so many is listen and ask. Listen to what your patient tells you. The problem is for them, whether it's a parent of a child or you're working with an adult or an older child or, you know, adolescent, this is going to be so telling, so, so telling. Like if you take nothing else away from today, listen to your patient. Listen to your patient. You don't know more than them. You are no better than them. You are there for them. They're coming to you because they need help. Put your ego aside, listen to what they are telling you and then use your clinical skill set to help them. Right? I get so many people coming to me saying, well, they didn't come back after the evaluation or they didn't start therapy or they didn't complete therapy. How do you get people to go through therapy? Well, are you listening to your patients? Are you listening to what they're telling you? Their chief complaint is, are you listening to what brought them here in the first place? Because you can get them to do a lot of things if you just listen. And so many therapists struggle with this. They are not listening to their patients. They're not. And then I want you to ask, I want you to ask some key questions, okay? And we're not going to obviously go through like an Entire evaluation and treatment and podcast episode right now. But I want you to ask about their sleep because a lot of parents will tell you the child's sleep is great. They sleep all night. Great. So do my kids. If I lay in their bed. The younger one, without her, without like a. She's currently uses a myo brace just to, like, hold the expansion she got. She still needs more expansion. So it's not, in my opinion, an expander by any stretch of the imagination. It's keeping her from grinding her teeth. So why is she grinding her teeth without that in her mouth? Hmm. We should look into that. Right? And then from a parent standpoint too, like, great. My kids don't wake me up in the middle of the night. If they wake me up, it's very rare, very rare. And I'm like, what's wrong? They don't typically come to my bedroom and wake me up. So why are they waking up? Many times children who wake up in the middle of the night may be struggling with an airway issue. If their palate is high and narrow, if they are still sucking their thumb, if they are sleeping with their mouth open, if you can hear them breathing at night, right. Maybe they're not snoring, but you can go, you can hear. We shouldn't hear that. Sleep should be silent. Silent, okay. So when a parent says this, even though I always tell you, listen to. Parents listen to patients. If they tell you they don't snore, they don't sleep with their mouth open. Like, don't take this at face value. That's like the one, one thing that I don't always listen to. I will say, hey, could you snap like a three minute video of your child sleeping, like an hour after they've fallen asleep and send it to me? I want to see what the child's doing. I want to see what position they're in. I want to see how their head is positioned to their neck, to their shoulders, to their chest. Are they, you know, anyways, there's a lot that we can get into here, but those are just, like two really big tips I want you to focus on. And then do they have a history of, like, noxious oral habits? Right. Any respiratory concerns, history of orthodontia, dental work, you know, now or in the past? Tether girl, tissues. Any concerns there? Right. I'm going to gather a lot of this information in the case history. Obviously, we know our intake forms. Review, like, what they think the, you know, their chief complaint is. Medical history, family history, dental history, oral habits, Feeding history, you know, if anybody else is currently working with the child and who and so on and so forth. Right. But my MYO assessment goes through a lot of things and I'm going to just kind of list off some of what it goes through so you can have a good, better idea of what it entails. I like to go least to most invasive in terms of what I'm asking a child or a patient to do because I want them to build rapport with me and yes, we can do that during the eval. I want them to start trusting me. I want them to be more comfortable. If you go right at their face and in their mouth to just try and get something out of the way, they're going to be on high alert. It's not a good, it's not a good approach. I'm sorry, it's just not. We have got. Just think, pretend like you're working with a 2 year old who like 2 year olds make you earn their trust a lot of times like some kids will come straight to you, but other kids are going to make you work to earn your trust. And so an adult and an older child may be more reserved and they may not make you work as hard, but you got to earn their trust in the same way. So least to most invasive is super important. Okay. You know, in my course and even in the training that I do in the my own membership, I go over like the tools that are needed for the assessment, like what I recommend, like what type of photos to take in the initial assessment. I'm going to look at rest, posture. We talked about that already. Nasal mouth, you know, versus mouth breathing, their airway. Is their nose patent? Like do they have allergies? They present with allergic shiners. Any history of sinus? Sinus, sinus, sinusitis. Why can I not say that today? Any concern with their adenoids, tonsils, etc? Right. Their lingual mandibular differentiation, how well are they using their tongue separate from their jaw? Is everything working as one unit? Are we working into individually as we should be? Because all children by the time they're appropriate for a MYO eval should have lingual mandibular dissociation and differentiation masseters. Like what does their master masseter muscle look like? Their mental masseters, there's two of them, like one on each side. Their mentalis muscle, our chin muscle. I'm going to assess their temporomandibular joints. I'm going to. And I'm not assessing the joint directly. I'm really just kind of Palpating it to feel what the muscles around it are doing and do I feel the joint popping at all. Right. And sometimes again, like this is not to diagnose because diagnosing anything bone related is out of my scope. I'm allowed to diagnose based on muscle, fascia, soft tissue. Right. Not the hard tissue, bone stuff. So, you know, I might look at dental occlusion, but I'm not going to diagnose dental occlusion. I will make notes, I will refer onwards. If somebody has given me something from a dentist or orthodontist or oral surgeon or something, I might include that information in my report, but I will be clear of where I got that information from. Right. I will look at the hard palate as well and the vlm, the soft palate. What is their lip closure like? Right. How well is, are their lips functioning? Are their lips strong enough to even maintain closure? Is there something else preventing them from maintaining closure if they're not? Such as bone. Right. Mal occlusion maybe, or position of their jaws, facial. Facial symmetry or asymmetry. Right. I mentioned tonsils before, but tonsils and even tongue position as it relates to, to tonsils and then tongue position just generally on its own, their gag reflex. Now, these days we don't typically gag patients. I was taught to in my first MYO course I ever took and I was like, this is so unpleasant. And I'm pretty sure that people know if they have a heightened gag. So like I, I just trust and I. You're going to see it in a child pretty easily when you're doing other stuff. If it's too far forward in an adult or an older child, I just ask. They know I'm going to assess tethered oral tissues. And because I'm a speech language pathologist, I can also assess the oral phase swallow, you know, beyond the oral prep. Like in Mayo, you can look at oral prep and everything leading up to the point of swallowing actually happening. But as soon as that swallow is triggered, that is no longer the scope of a MYO eval that be goes into a swallowing eval. And that can only be assessed by a speech language pathologist. When you're going beyond that oral phase and then there's speech because again, I'm an slp, I'm a speech pathologist, so I can look at that. So I'm not going to go too much further into this just in terms of like how I break everything down. But I wanted to go over like what is looked at in a mile assessment Because I have therapists, I have, you know, non therapists, I've got people from all over, other colleagues asking, like, what are you even looking at in an evaluation? So hopefully this sheds some light because when we move into assessment, a lot of what we are assessing is going to come out of what our findings were in the evaluation. Right. And so we need to know what this, what the child or adult, what that person sitting in front of us is able to do, what their restrictions are, you know, how functional are they and if function is impacted, what part of their function is impacted and what is the root cause, like what is the root behind that. We know for a child, for example, that maybe mouth breathing that has a V shaped, high, narrow palate, the tongue doesn't fit up there. So to even work on getting the tongue up there when there isn't space for it doesn't seem appropriate. Right. So that might be a referral out to an orthodontist or a dentist who can do earlier expansion on a younger child or just, you know, expansion at any other point of the life, really. Because, you know, we do believe that the tongue shapes the palate. And if it is not up there to shape the palate, the palate starts to collapse. And that's where we start to get these more high vaulted, you know, skinny shaped, U or V shaped palettes. There's all different kinds of palette presentations out there these days. I'm not going to go into all of that again. But it's really, really important to look at and to consider because if the tongue can't function to do its job, obviously surrounding, you know, anatomical structures are going to be impacted. That shouldn't be that hard to kind of like grasp just in terms of like concept, right. When you start to see it, you start to go, oh, oh, okay, now I get it. All right, so with all that said, right, as I mentioned, the oral prep phase, when we're starting to look at treatment and everything, we need to remember that the oral prep phase is the start of the swallow. Excuse me, we place food in our mouth, it's controlled by our tongue. We moisten that food with saliva to create the bolus, that ball of prepped food in the center of our tongue. Right. If you're properly chewing that food, you're going to be able to like a rotary chew. You're going to be able to form that bolus. You gather on the center of your tongue, as I mentioned, in one cohesive unit, and that's that oral prep part of the oral phase. Swallow okay, the oral prep phase. Then the oral phase evolves into, like, your tongue shaping into a bowl and holding that bolus against your palate. And then there's this peristaltic motion of the tongue that pushes the bolus back. The back of the tongue drops to allow the swallow to happen. The tongue pushes the bolus back, you know, towards the throat. The swallow is initiated, and that's where MYO ends. So that is what we're working on. And if, if we're struggling with that, if we're struggling that correct oral rest, posture and keeping our tongue up in the roof of the mouth, breathing through our nose, keeping our teeth slightly apart with our lips together. If we're struggling with that, correct oral rest, posture and nasal breathing. And we have some of these other things I mentioned earlier going on. That is what we are working on in the treatment side of the MYO picture. Okay, so I wanted to go over that. Speech is not myo. An SLP who's doing MYO can also address speech at the same time. Um, if there's picky eating, you know, an SLP or an OT can address that at the same time. But in a traditional MYO program, those things are not addressed. Because what I just mentioned did not include, like, picky eating, food aversion, you know, dealing with that, or expanding diets and textures and all that fun stuff like that requires a license of a feeding therapist. And so sometimes there are feeding things that are pulled into MYO or speech things that might be pulled into myo, but it's really important to kind of understand where the line starts and where the line ends. When it comes to treat, assessment and treatment of myofunctional therapy or orofacial myofunctional disorders, I should say. So, as I mentioned, like in my course, I give you a report, template, sample report, common codes that we bill, all that fun stuff, some of that, like the codes and everything are also available inside the MYO membership. I also have an entire training on assessing, as I mentioned, inside the MYO membership, along with a separate training on how to make sense of the results. Right. We actually assess somebody for you to see. We, you see, you see me go through an assessment, and then you can also do a self assessment on yourself with. Many of us do when we're going through this for the first time, and then we basically make sense of it and we create a treatment plan together. And so what I wanted to point out is that you can complete assessments in person or virtually. There are some people who feel very strongly about only doing in person evals. And I will, I'm here to tell you that, you know, the pandemic, it proved to us that we can do Mayo virtually very successfully. That said, the person that you're working with should be licensed in the state in which you live in or a country in which you live in. You know, it depends like where you live out, if you're inside the U.S. or outside of the U.S. but I think it's really, really important to understand what you're looking at and understand, you know, and have done maybe some like in person assessments first, just so that you understand what you're trying to do virtually. Because to not be able to put your hands on faces, it is a little bit of a disadvantage. But you start to, you start to see things visually. And you can also guide an old, an older patient, say older patient, like a adolescent, even through adulthood, you can guide an adolescent through adult to feel things on their own face and report back to you. And then you also can visualize them doing this so that, you know, over a virtual appointment, you're able to see what's going on. Right. Because it is just not possible for everybody to have in person everything all the time. Right. Just depending on location, remote locations and whatnot, and who's available in your area. In the MYO method, I will also add that we do have pediatric, virtual and in person evaluations of both children and adults in each category for you to watch. So that's really fun because by the end of that, you've seen me do a lot of evaluations. They're all different ages, like 4 year, 4 years, 6 years, 17, 26, 64. So you get a really good feel for like different evaluations, as I mentioned. And then, yeah, clarifying what you're like finding, making sense of it all and pulling it into this kind of, I don't want to call it a framework, but really understanding what you're doing in, in treatment so you understand how to treatment plan. You know, therapy is most likely going to address something like eliminating oral habits, which is a whole nother conversation for another day. Because I know we no longer really do oral habit elimination programs. If you're doing MYO properly, the habit typically eliminates itself during the MYO program. And if it doesn't, then you can address it towards the back end of the program. But that's again another conversation for another day. We're looking at, you know, your tongue resting posture, your lips, their resting posture is nasal breathing established. You know, if you're a speech pathologist, you might be looking at oral function for speech, you're definitely looking for oral phase bolus prep and that initiation of the swallow or at least getting to that initiation point if you're not someone who can treat the swallow. And then maybe there's referrals that you make as well. Right. Which is again, a much longer, longer conversation for another day. But I wanted to just mention this because when we are treatment planning, we need to make sure that we're not like, working against anything that's going to hinder progress. So I mentioned earlier, like malocclusion, you know, open lip posture, mouth breathing, a sucking habit can also hinder progress. But again, there's ways to address that through the MYO program. Drooling. If there's actual like, like lingual weaknesses or other weaknesses in the oral musculature, if there's oral appliances that might be in the way, resting postures of the lips, you know, the chewing bolus prep, oral face swallow, swallow, you know, if they're doing excessive cleanup, swallows, if they're maybe drinking, you know, is someone drinking from. Someone drinking from like an open cup, a straw cup, a water bottle, like, what are they able to drink from? Right. Because we may be wanting to work towards some of these things. And is there something that they're doing that's hindering them from doing this? Is there something that's hindering them from collecting their saliva properly and managing that saliva? Right. And so on and so forth. So we need to make sure that we are looking at, we're coming at this holistically and trying to figure out the root behind what we're seeing. Okay. There's many different paths from treatment, you know, or sorry, from referral, you know, to graduation, from starting that assessment to starting therapy, to graduating. Right. So. So I've talked about this in the past. I'm not going to go through like, all the different kinds because it could look, there could be like, literally like dozens of different ways that patients come through and experience a treatment plan. It's not the same for everybody. And that's what I mean when it should be, you know, individualized. Some people might come in and go straight from assessment to myo, or others may need to go be referred to a dentist for an assessment with them. And maybe they need a growth appliance first, maybe they need a frenectomy, or maybe they come from the dentist to us. They've already had an assessment with them and now they need an assessment with us. But they're still going into a growth appliance, right? And so it's not time yet for mild. MILE will come later. Or maybe they need my own now and we're prepping for a release and they're going to go into an appliance after. I have seen it so many different ways and truly to individualize the process, there is no, like, singular right way. Because a lot of people will ask me, like, what is the best option? And I can tell you what was best for me, what I wish I had done differently for myself, what I've done for my kids, and what I maybe wish I had done differently for one or like one of them, you know, like, I can tell you these things, but that doesn't mean that it's going to be the right process for everybody else. So that's where it becomes really important to take the right course, to get connected with the right community of MYO professionals and colleagues and get the support that you need because all of your cases are going to be different, right? So Again, in the MYO membership, which I mentioned, doors open October 21st through 25th. Get on the My Weight the Mile wait list at the mymembership.com Little shameless plug there. We do have an incredible, incredible community of certified mentors, trained mentors, people who have been doing this for years now, who run office hours, who run our study clubs, who are in there answering questions 24, 7 in our private group. Some of them are even doing some of the monthly trainings. But we bring in other specialists as well for those monthly trainings on topics that the community asks for. So there's just, there's so much goodness. There's research reviews, like we do four per month dating back to January, June of 2020. So there's just tons of research reviews in there, tons of other materials as I've shared a marketing library, business trainings, like so much goodness. So definitely want to hop in there. If this is not something that you are familiar with or if you're just getting into MILE or you're looking to grow your miles skill set or connect with colleagues, colleagues who are in the MYO space. This is the space for you. We are the, like original Mayo hangout, online, online study club and all that fun stuff. So come hang with us. I look forward to meeting you and seeing you in there. For now, this is Hallie signing off and we'll chat. We'll chat next week. 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 I 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 Allie Balkan on Instagram to get all the latest updates.