Adults with severe dyspraxia and myofunctional disorder

Background:  This patient had been seen 3 times by L, an SLP graduate of my 28 hour course.  He was coming to Orlando to see friends and a consult was set up.  My findings and suggestions follow her email.

Hi Sandra,

So glad that you were able to meet with R. I have been perplexed about him. His OM issues seem to be compounded by his difficulty with nasal breathing (polyps), poor motor planning, and weak sensation around his lips and tongue

 

My basic results from exam:

1. Unable to do fat/skinny— this was lost on him.    

2. Able to elevate only after significant amounts of stimulation

3. Able to move tongue laterally but without precision or consistency

4. Able to move tongue horizontally but without precision or consistency

5. Velum ok–able to say Unnnngah

6. Unable to achieve palatal seal when asked to do so (can’t click) however, was able to suck through a straw so that tells me that he is physically able to create the seal. 

7. Type 1–normal dentition with diastema

8. Unable to form lingual palatal seal for water hold

9. Weak masseters–unable to bite and activate masseters when asked to do so. However, when given chewy tube, masseters activated.

10. Chewing–characterized by chomping, lips apart. Food residue after swallow, scatter (vs. cohesive bolus) present just before swallow.

11. Unable to puff cheeks–are buccinators weak?

R is obviously experiencing multiple difficulties. He had come to each session accompanied by 1-2 graduate students. Evidently he has about 8-9 assistants that help him with daily living tasks. While he obviously has oral facial deficits, he is clearly verbal and articulate. I see his difficulties with planning, time management, and prioritizing as more important than these OFM concerns.   I realize however that this is not my call as to what he decides to work on but I did feel a responsibility to share my opinion. I referred him for a neuropsych assessment with hope of helping him qualify for some sort of state assistance with these tasks of daily living.

That being said, I am happy to work with R and feel that OFM therapy will benefit him in the social realm with learning a more correct way to eat. Currently he chomps, eats with mouth open (polyp impact), and must wash his food down with large quantities of liquid (he can’t eat without a drink.)

What were your findings? I would love to hear your thoughts and truly welcome any ideas that you have!

Thanks so much again,

L

 

Dear Graduate:

Here are my findings and beliefs about R’s situation.  To start off, he is SEVERELY apraxic; it seems so bad that I am more comfortable saying A-praxic rather than DYS-praxic, though both words are used interchangebly by many.

That apraxia rules all…..explains most of the problems we see.  He can’t willfully demonstrate even the most simple volitional oral act (it does appear to be far more than just “oral apraxia” as his gait and breathing are affected.  He can’t breathe when or how he is asked to do so; holds his breath when performing non-respiratory actions requested; doesn’t demonstrate arms/legs left-right laterality during walking per report and brief observation.  He has wondered all his life why he couldn’t succeed in many tasks but from what he says therapists, teachers, etc. always started their program of treatment above his basic ability limits.  If he can’t even stick out his tongue and pull it back inside when asked, how in the world can he be expected to do higher level tasks?

 

This is surely an example of why I hesitate to call what I teach simply “orofacial myology” since so much else must be considered and implemented…..you are correct that orofacial myology is not a priority (except in the broad term that you and I and other SLP grads use orofacial myology and the Myo Manual approaches).   Be as basic and simple as you can possibly be.  Don’t feel that you have to cover more than one or two things during a session…proceed SLOW, REPEAT…SLOW, REPEAT

DO WITH MIRROR, TRY WITHOUT MIRROR (probably work better without mirror for many tasks since the reverse image of the mirror is likely to confuse him further). 

 

He has the prescription sheet with my recommendations but I’ll put it below:

 

1. Masseters:  Goal:  AWARENESS,  to “feel” the bumps come and go.  Use tongue depressors on both sides, bite, and feel the change.  Use also on one side to compare, etc.  The importance is that he becomes aware of this simple act of squeezing back teeth together (he had no idea what that meant initially, even when feeling my masseters and directing me to squeeze them).   He must realize and connect the act of squeezing molars with the “bumps” arising in the masseter areas.

 

2.  Horizontal lingual independence:  Use 2 way mouth props on both sides, out of the way of the tongue.  In his case you have to use the  widest opening you can.  Then he is to put tongue out….PAUSE for a few seconds…..then tongue in…PAUSE again for a few seconds.  Do this EXTREMELY slowly so that he can connect the action with the result. (neuromuscular facilitation). See below for further information on neuromuscular facilitation. 

 

3.  Click – begin at whatever level he can, even if only smacking noises with tongue extended….. and slowly work toward accomplishing click with tongue inside.  Then to Suctioning.

 

4.  Suctioning: Use dent tips with sponge on stick.  Place into cheek/buccal area on one side at a time; have him resist as you try to pull out the dent tip; one of the other goals is to have him do so without using the bite reflex, which he demonstrated during examination and probing.

 

5.  Begin very basic thereafter with suctioning of cheeks and puckering lips, once again starting wherever he can and slowly progressing.

 

6.  Buccinator:  Have him “breathe easily,” allowing air to fill cheeks and then helper/therapist uses gloved hand to close/seal his lips for a second so he can feel his cheeks puffed out with air.  I found that he cannot puff up his cheeks with air and was able to get him to do so by lightly blowing outward and then I caught him during the puffiness and sealed his lips with my gloved hand, holding it for a second or two as he felt the filled cheeks.

 

7.  Elevator Disk Hold:  STAY BASIC!  Goal: with 2WMProps holding jaw open on both sides, he is to hold braiding with tongue to anywhere on palate that he can (WITH MOUTH OPEN!).  Start anywhere  you can (mid tongue far back, tip far back, whatever……) Maximize as able.

 

Regarding his nasal polyps, only one side was not patent, but he has agreed to see an ENT to eliminate any obstructions.

 

Good luck and thank you for sending R to me for my input.

Sandra

 

 

Note:  with R, I doubt that I would use elastics or any other objects that are inedible since he has little control or awareness…and could inhale or swallow objects by mistake. Also, use 2 Way Mouth Props rather than 3 Way as he will easily flatten the 3 way props.  See Appendix in Myo Manual to review benefits and disadvantages of both types of Mouth Props.

 

What follows about proprioceptive neuromuscular facilitation was written for OT or PT, but we can extract much from the concepts and apply them with R.  Because of the apraxia, progress can be expected to be painfully slow, but I believe that once a base is solidly formed, progress in related areas may be faster. 

PNF (proprioceptive neuromuscular facilitation) results in impulses being sent to the brain, which leads to the contraction and relaxation of muscles. When a body part is injured/damaged, there is a delay in the stimulation of the muscle spindles and golgi tendons resulting in weakness of the muscle. PNF exercises help to re-educate the motor units which are lost due to the injury/damage. 

To perform PNF exercises, it is important to remember the following principles:

• Patient must be taught the pattern.
• Have the patient watch the moving part moved passively.
• The trainer must give proper verbal cues.
• Manual contact with appropriate pressure is very important.
• Contraction of the muscle group is facilitated by hand placement.
• Apply maximal resistance throughout ROM.
• Resistance will change.
• Rotation of movement will change throughout ROM.
• Distal movement should occur first and before halfway through movement.
• Use maximal contraction to promote overflow of strength.