Hi Sandra, So glad that you were able to meet with my patient. 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. For sure…at the very least! My basic results from exam: 1. Unable to do fat/skinny— this was lost on him. cannot perform any task consistently or with ease, not even sticking tongue out and in. 2. Able to elevate after significant amounts of stimulation 3. Able to move tongue laterally but without precision 4. Able to move tongue horizontally but without precision 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? He is obviously experiencing multiple difficulties. 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 him 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!
Here are my findings and beliefs about your patient’s situation. To start off, he is SEVERELY apraxic; it seems so bad that I am almost 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 act (it does appear to be far more than simple “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 use 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 above his basic ability limits. If he can’t even stick out his tongue and pull it in when asked, how in the world can he do higher level tasks? This is surely an example of why I hesitate to call what I teach simply “orofacial myology”…you are correct that orofacial myology is not a priority (except in the broad term that you and I do orofacial myology). 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…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 sheet with my recommendations but I’ll put it below in black: 1. masseters: Goal: AWARENESS, to “feel” the bumps come and go. Use tongue depressors on both sides and bite and feel the change. Use alsounilaterally to compare. 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 (his bite reflex warrants 2 Way instead of 3Way Mouth Props), out of the way of the tongue. Then he is to put tongue out….PAUSE awhile…..then tongue in…PAUSE awhile. Do this EXTREMELY slowly and hope that the brain connects with the action (neuromuscular facilitation). What follows is specifically for OT or PT, but we can extract much from the concepts and apply them with him. 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 are likely to come 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. 3. Click – begin however he does it and slowly work toward doing it with tongue inside. 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. 5. Begin very basic thereafter with suctioning of cheeks and puckering lips, as able. 6. Breathe easily, allowing air to fill cheeks aqnd therapist closes 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: 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 with anything you can get (mid tongue far back, tip far back, whatever……) Good luck, and thank you for sending your patient to me for a second opinion. Sandra Note: with him, I doubt that I would use elastics or any other objects that are unedible since he has little or no control or awareness…and could inhale or swallow objects by mistake.