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A subcortical approach to swallow pattern therapy
A subcortical approach to swallow pattern therapy Mervyn 1. Folk, Ph.D.,* Marianna Sari Toth, M.Ed., O.T.R.***
Detroit,
Wells,
O.T.R.,**
and
Mich.
S
peech pathologists have worked with orthodontists since the 1950’s in an attempt to establish adequate swallow patterns in patients diagnosed as manifesting tongue thrust. Apparently, speech pathologists were originally called upon by orthodontists to establish normal patterns of deglutition since speech pathologists were thought to be most familiar with oropharyngeal physiology. A number of tongue-thrust therapy programs soon evolved and, although there were some differences among those who advocated various rationales and procedures, it was generally accepted that the approach to the establishment of normal swallow patterns would be of such nature as to require conscious application of the principles being taught. However, a relatively high incidence of failure from therapy, as well as regression following therapy, has been observed by the present investigators. Failures have been attributed at least in part, to lack of motivation as well as to interpersonal factors in the patient-clinician relationship. In addition, it would seem illogical to expect a person to “think” about where his tongue belongs as he swallows each of 1,600 to 2,500 times daily. Therefore a re-examination appeared indicated of the traditional (that is conscious-level) model heretofore utilized in an effort to establish normal swallowing. It seemed most reasonable to attempt to teach a new swallow pattern on the subconscious level since swallowing is essentially a subcortical function. One means of subcortically affecting muscle function is neuromuscular facilitation. It appeared feasible to us that application of this treatment technique might well be made to the muscles of deglutition. Therapeutic procedures were subsequently established and an experimental population was formulated *Associate sity, and **Supervisor Children’s ***Former Michigan.
Professor, Director, of Hospital Director,
Communication Disorders and Sciences, Maxillofacial Research Center, Children’s
Clinical
Student
Education,
Department
of
Wayne Hospital Occupational
State Univerof Michigan. Therapg.
of Michigan. Department
of
Occupational
Therapy,
Children’s
Hospital
of
419
420
Palk, Wells, and Toth
Am. J. Orthod. October 1976
in order to test the validity of the concept. It is the purpose of this article to report the results of the application of neuromuscular facilitation principles to the treatment of tongue thrust. Observable improvement in anterior dental relationships is thought to be sufficient evidence of the validity of such a treatment method. NO projections of treatment success beyond one year are intended; nor is there reason to hypothesize that the use of orthodontic appliances can be eliminated. The
neuromuscular
facilitation
technique
of
Rood
A technique of neuromuscular facilitation was developed by Margaret Rood, O.T.R., R.P.T., and is used by occupational and physical therapists in the treatment of physical disabilities. As Huss5 indicates : R,ood defines her technique as “the activation, facilitation, and inhibition of muscle action, voluntary and involuntary, through the reflex arc.” The media used by Miss Rood (positioning, brushing, icing, pressures, and resistance) are used as a means of stimulating the sensory receptors (exteroceptors, interoceptors, and proprioceptors) to obtain a motor response (extrafusal and/or intrafusal) through the reflex arcs. Thus, results can be obtained mitho~t voluntary cortical control by the patient. In fact, initial attempts at cortical control of specific movements may block the stimuli put in which negates the results and the patient reverts to previous abnormal patterns of movement. . . . most . . . sensory input is correlated with motor activity on a subconscious basis. Therefore, when we apply stimulation to increase the sensory inflow to the central nervous system, the patient must be provided with a followup activity which utilizes on a subconscious level the motor patterns stimulated.
Moore6 further
states :
When properly used, we believe that exteroceptive and proprioceptive stimuli can help bombard the central nervous system thereby lowering the threshold of motoneuron pools to the extent that action can be expressed through them by higher centers or specifically by reflex action in response to these stimuli. When certain stimuli are used in rehabilitation, repeated over and over again, and followed up with meaningful activities which help to reinforce them, then we feel that we may be able to build in or condition the nervous system to respond with more purposeful movement patterns. It is felt by several investigators that these exteroceptive stimuli affect the gamma loop system which in turn helps control or govern the alpha motoneuron system. Procedure
An experimental group of eleven children ranging in age from ‘75 months to 165 months, with a mean age of 115.6 months, was referred to the investigators at Children’s Hospital of Michigan by orthodontists in metropolitan Detroit. Six subjects had previously worn some type of orthodontic appliance; none, however, wore appliances of any sort during the experiment. The experimental population consisted of four boys and seven girls. Dental models and cephalograms of each patient were made by the referring orthodontist prior to initiation of this particular swallow pattern therapy regimen. Subsequent models and cephalograms were made by the referral sources at 3 months, 6 months, and 12 months following initiation of the program. Each child was seen with a parent for evaluation and instruction in the program by a speech pathologist and an occupational therapist, Each subject was seen again with his
Subcortical
Fig. 1. Lateral following
views application
of of
1 1 O-month-old neuromuscular
approach
to swallow
pattern
therapy
boy showing improvement and no facilitation principles to swallow pattern
421
regression therapy.
parent 1 week later in order to determine that the technique was being applied as originally demonstrated. Subsequent visits were made monthly by each subject and parent. Subjects were maintained on the therapy program for 6 months and were then removed from the program. Dental models and cephalograms taken at 0, 3, and 6 months were then available. After a subsequent 6-month lapse of time, during which no therapy was administered, additional models and cephalograms were made. Dental models and cephalograms thus provided a basis for comparison at varying stages in therapy and also for determination of possible regression. Precisely articulated
422
Falk,
Wells, and Toth
Fig. 2. Lateral views of dental before and after 6 months of
models swallow
Am. J. Orthod. October I976
of 118-month-old pattern therapy.
girl
showing
treatment
results
dental models were examined for changes in anterior dental relationships by the staff of the Department of Orthodontics, University of Detroit Dental Center. Cephalometric measurements were also attempted in order to quantify the empirical data. Measurements were made of SNA, SNB, ANB, LNA (mm.), LNA (degrees), iNB (mm.), and iNB (degrees). Results
Results of the study, as demonstrated by serial dental models for five selected subjects, appear in Figs, 1 to 5. ‘Fig. 1 is representative of the subjects
S&cortical
Fig. 3. Lateral of
swallow
views pattern
of
dental
models
approach
of
86-month-old
to swallow
girl
puttern
before
and
therapy
after
423
6
months
therapy.
who demonstrated no observable regression following completion of the active treatment procedure. Figs. 2 to 5 demonstrate results with subjects of differing ages at various points in time during and after the experiment. Comparison of serial dental models made at 0, 3, 6, and 12 months indicates for all subjects that reduction in the distortion of anterior relationships was observable after the application of neuromuscular facilitation principles to swallow pattern therapy, In addition, nine of the eleven subjects demonstrated no observable regression during the 6-month period which followed the therapy regimen, as determined by examination of their serial models. Attempt.s to quantify the results noted through visual examination of the
424
FalF;, Wells, and ToA
Fig. 4. Lateral views of dental models before and after 3 months of swallow
of 161-month-old pattern therapy.
girl
showing
treatment
results
dental models were negative. It was also found to be virtually impossible to obtain reliable data from cephalograms for accurate quantification of observed changes, since a number of technicians were responsible for making the films ; hence, there was a reduction of internal consistency among the experimental population. Discussion
A number of observations can be made after having conducted the present experiment. Foremost, perhaps, is the fact that we successfully worked with children manifesting tongue thrust who were of a younger age than are children who are normally placed into a more classic swallow pattern therapy program. In addition, it is to be noted that patient cooperation may not have been the critical ingredient in the experimental program that it appears to be in a more traditional program. Both of these observations appear to be reasonable, since conscious application of tongue-placement principles is unnecessary when
Volume Number
70 4
Fig. 5. Lateral tionships and
Subcortical
views dental
of dental relationships
approach
to swallow
models of 75month-old boy 6 months after completion
pattern
therapy
425
showing original dental relaof swallow pattern therapy.
neuromuscular facilitation is used; that is, the normal swallowing process, as it is being learned, need not be intellectualized. The lack of a need to consciously control the swallowing procedure in itself seems to contain certain implications: (1) Perhaps tongue-thrust therapy for the mentally retarded can now be a more viable concept than it is under traditional training conditions; (2) further, the use of neuromuscular facilitation may well be applicable in both growth discrepancy and neurologicaly involved patients, both of whom, again, have usually been rejected for therapy under traditional conditions. Selected factors possibly associated with tongue thrust were also studied. These data allow certain additional observations to be made. With regard to the various parameters evaluated, virtually no difficulty with tongue movements was noted. In addition, with rare exceptions, there were no problems with categories indicated as tongue abnormalities. Further, it is of interest to note that of eleven subjects, one boy and five girls could not whistle; this may be associated with a possible social tendency away from girls learning to whistle. In addition, only one subject who was unable to whistle was somewhat younger than the T-year age by which children arc said to be old enough to be able to whistle .4 No subject had difficulty with blowing.
426
Frrlk, Wells, md
Toth
Nine of the eleven subjects had a history of t,humb- or finger-sucking. The mean age at which this activity ceased for four subjects was approximatel60 months. Further, five subjects, with a mean age of 105 months, were reported to suck their thumbs or fingers occasionally at the time this experiment was initiated. Seven of the subjects had a history of mouth breathing; two subjects had an early history of abnormal drooling; and four subjects had an early history of hyperactive gag reflex. It is of further interest to note that four subjects were breast fed to a mean age of 5.62 months, and nine sul)jects were bottle fed to a mean age of 10.1 months. The discrepancy in this total is due to the fact that two subjects went from breast feeding to bottle feeding and two subjects went from breast feeding to a cup. Eight subjects did not use a pacifier; whereas three subjects used a pacifier to a mean age of 28 months. The mothers of six subjects had no objection to a pacifier. In addition, six of the eleven subjects received a mean of 1.7 school years of speech therapy. No subject received speech therapy prior to entrance into school. Speech evaluation at the outset of the experiment indicated that ten subjects had some form of sound-production error, In eight of these ten cases, the error could be associated with oversibilance as a possible function of the dental relationship present at the time of screening. Of these data, three factors appear to be common to the history of the child with tongue thrust: thumb-sucking, mouth breathing, and articulation error. The latter may be explained as a function of the dental relationships2; however, the other two factors seem to be related, at least in part, to the onset of tongue thrust. These findings suggest support of the concept reported by GarlinerY relative to the influence of perioral musculature in addition to tongue musculature in normal deglutition. Additional observations can be made on the basis of having conducted this experiment. Of the total population referred, only two children did not complete the program. The fact that eleven of thirteen subjects remained in a program which extended over what might seem to the patient to be a lengthy period of time may imply that the neuromuscular facilitation approach to swallow pattern therapy requires less cooperation and motivation than is inherent in previously reported therapy programs, Reasons for this may include the fact that the program is not particularly time consuming, nor arc bhe activities either socially unacceptable or acosmetic. Further, the child can ra,ther easily selfadminister treatment, thus eliminating the need for a parent to be totally involved in therapy. It can also be inferred that the relatively brief period of treatment with neuromuscular facilitation appears to contraindicate the possible effect of spontaneous improvement on the swallow pattern. Previous investigators have found that spontaneous improvement occurs until the age of 8 years.2 Such a finding would not appear to be related to the current study.
Volume Nmnber
70 4
&&xwtical
approach
to ~~nllow
pattern
therapy
427
Nine of the eleven subjects showed no regression 6 months after treabnent ended. It would nevertheless appear necessary to direct attention to the two sub jeets who did manifest some regression. Such regression may have bcm prevented if a partial program of reinforcement had been used during the second 6-month period during which no treatment was administered. Such a J’roctldur( would be consistent with results of other human learning experiments.’ Sum’mary
The neuromuscular facilitation technique was experimentally used with tongue-thrust patients in order to examine the results of application of this technique to such a population. Four boys and seven girls with a mean age of 116 months were referred by orthodontists in the greater Detroit area to Children’s Hospital of Michigan. Each had previouslp been diagnosed as mani-festing tongue thrust. Brushing, icing, and pressure were applied in a home training program fol 6 months. Serial dental models were made at 0, 3, 6, and 12 months, the latter* being used to detect regression 6 months after termination of the therap) regimen. Results are presented to support the contention that neuromuscular facilitation is a useful technique in swallow pattern therapy. Ancillary findings arc’ presented which support the contention that mouth breathing and thumb and finger-sucking precede the onset of tonguo thrust. REFERENCES
1. Doerfler, L., and Stewart, K.: Malingering and psychogenic deafness, J. Speech Hear. Disord. 11: 181-186, 1946. 2. Fletcher, 8. G., Casteel, R. L., and Bradley, D. P.: Tongw thrust swallow, speech articultition, and age, J. Speech Hear. Disord. 26: 201-208, 1961. 3. Garliner, D.: Myofunctional therapy in dental practicr, Brooklyn, 1971, Bartel Dental Rook Co., Inc. 4. Gesell, A., and Ilg, F. L.: The child from five to ten, Nex York, 1946, Harper & Rrothers. 5. 11~8, J.: Application of the Rood techniques to treatment of the physically handicapped child. In West, W. L. (editor) : Occupational therapy for the multiple handicapped child, Chicago, 1965, University of Illinois. 6. Moore, J. C.: Neuroanatomical and neurophysiological factors basic to tile use of neurw muscular facilitation techniques. In West, W. L. (editor) : Occupational therapy for the multiply handicapped child, Chicago: 1965, University of Illinois.
Detroit,
Wells,
O.T.R.,**
and
Mich.
S
peech pathologists have worked with orthodontists since the 1950’s in an attempt to establish adequate swallow patterns in patients diagnosed as manifesting tongue thrust. Apparently, speech pathologists were originally called upon by orthodontists to establish normal patterns of deglutition since speech pathologists were thought to be most familiar with oropharyngeal physiology. A number of tongue-thrust therapy programs soon evolved and, although there were some differences among those who advocated various rationales and procedures, it was generally accepted that the approach to the establishment of normal swallow patterns would be of such nature as to require conscious application of the principles being taught. However, a relatively high incidence of failure from therapy, as well as regression following therapy, has been observed by the present investigators. Failures have been attributed at least in part, to lack of motivation as well as to interpersonal factors in the patient-clinician relationship. In addition, it would seem illogical to expect a person to “think” about where his tongue belongs as he swallows each of 1,600 to 2,500 times daily. Therefore a re-examination appeared indicated of the traditional (that is conscious-level) model heretofore utilized in an effort to establish normal swallowing. It seemed most reasonable to attempt to teach a new swallow pattern on the subconscious level since swallowing is essentially a subcortical function. One means of subcortically affecting muscle function is neuromuscular facilitation. It appeared feasible to us that application of this treatment technique might well be made to the muscles of deglutition. Therapeutic procedures were subsequently established and an experimental population was formulated *Associate sity, and **Supervisor Children’s ***Former Michigan.
Professor, Director, of Hospital Director,
Communication Disorders and Sciences, Maxillofacial Research Center, Children’s
Clinical
Student
Education,
Department
of
Wayne Hospital Occupational
State Univerof Michigan. Therapg.
of Michigan. Department
of
Occupational
Therapy,
Children’s
Hospital
of
419
420
Palk, Wells, and Toth
Am. J. Orthod. October 1976
in order to test the validity of the concept. It is the purpose of this article to report the results of the application of neuromuscular facilitation principles to the treatment of tongue thrust. Observable improvement in anterior dental relationships is thought to be sufficient evidence of the validity of such a treatment method. NO projections of treatment success beyond one year are intended; nor is there reason to hypothesize that the use of orthodontic appliances can be eliminated. The
neuromuscular
facilitation
technique
of
Rood
A technique of neuromuscular facilitation was developed by Margaret Rood, O.T.R., R.P.T., and is used by occupational and physical therapists in the treatment of physical disabilities. As Huss5 indicates : R,ood defines her technique as “the activation, facilitation, and inhibition of muscle action, voluntary and involuntary, through the reflex arc.” The media used by Miss Rood (positioning, brushing, icing, pressures, and resistance) are used as a means of stimulating the sensory receptors (exteroceptors, interoceptors, and proprioceptors) to obtain a motor response (extrafusal and/or intrafusal) through the reflex arcs. Thus, results can be obtained mitho~t voluntary cortical control by the patient. In fact, initial attempts at cortical control of specific movements may block the stimuli put in which negates the results and the patient reverts to previous abnormal patterns of movement. . . . most . . . sensory input is correlated with motor activity on a subconscious basis. Therefore, when we apply stimulation to increase the sensory inflow to the central nervous system, the patient must be provided with a followup activity which utilizes on a subconscious level the motor patterns stimulated.
Moore6 further
states :
When properly used, we believe that exteroceptive and proprioceptive stimuli can help bombard the central nervous system thereby lowering the threshold of motoneuron pools to the extent that action can be expressed through them by higher centers or specifically by reflex action in response to these stimuli. When certain stimuli are used in rehabilitation, repeated over and over again, and followed up with meaningful activities which help to reinforce them, then we feel that we may be able to build in or condition the nervous system to respond with more purposeful movement patterns. It is felt by several investigators that these exteroceptive stimuli affect the gamma loop system which in turn helps control or govern the alpha motoneuron system. Procedure
An experimental group of eleven children ranging in age from ‘75 months to 165 months, with a mean age of 115.6 months, was referred to the investigators at Children’s Hospital of Michigan by orthodontists in metropolitan Detroit. Six subjects had previously worn some type of orthodontic appliance; none, however, wore appliances of any sort during the experiment. The experimental population consisted of four boys and seven girls. Dental models and cephalograms of each patient were made by the referring orthodontist prior to initiation of this particular swallow pattern therapy regimen. Subsequent models and cephalograms were made by the referral sources at 3 months, 6 months, and 12 months following initiation of the program. Each child was seen with a parent for evaluation and instruction in the program by a speech pathologist and an occupational therapist, Each subject was seen again with his
Subcortical
Fig. 1. Lateral following
views application
of of
1 1 O-month-old neuromuscular
approach
to swallow
pattern
therapy
boy showing improvement and no facilitation principles to swallow pattern
421
regression therapy.
parent 1 week later in order to determine that the technique was being applied as originally demonstrated. Subsequent visits were made monthly by each subject and parent. Subjects were maintained on the therapy program for 6 months and were then removed from the program. Dental models and cephalograms taken at 0, 3, and 6 months were then available. After a subsequent 6-month lapse of time, during which no therapy was administered, additional models and cephalograms were made. Dental models and cephalograms thus provided a basis for comparison at varying stages in therapy and also for determination of possible regression. Precisely articulated
422
Falk,
Wells, and Toth
Fig. 2. Lateral views of dental before and after 6 months of
models swallow
Am. J. Orthod. October I976
of 118-month-old pattern therapy.
girl
showing
treatment
results
dental models were examined for changes in anterior dental relationships by the staff of the Department of Orthodontics, University of Detroit Dental Center. Cephalometric measurements were also attempted in order to quantify the empirical data. Measurements were made of SNA, SNB, ANB, LNA (mm.), LNA (degrees), iNB (mm.), and iNB (degrees). Results
Results of the study, as demonstrated by serial dental models for five selected subjects, appear in Figs, 1 to 5. ‘Fig. 1 is representative of the subjects
S&cortical
Fig. 3. Lateral of
swallow
views pattern
of
dental
models
approach
of
86-month-old
to swallow
girl
puttern
before
and
therapy
after
423
6
months
therapy.
who demonstrated no observable regression following completion of the active treatment procedure. Figs. 2 to 5 demonstrate results with subjects of differing ages at various points in time during and after the experiment. Comparison of serial dental models made at 0, 3, 6, and 12 months indicates for all subjects that reduction in the distortion of anterior relationships was observable after the application of neuromuscular facilitation principles to swallow pattern therapy, In addition, nine of the eleven subjects demonstrated no observable regression during the 6-month period which followed the therapy regimen, as determined by examination of their serial models. Attempt.s to quantify the results noted through visual examination of the
424
FalF;, Wells, and ToA
Fig. 4. Lateral views of dental models before and after 3 months of swallow
of 161-month-old pattern therapy.
girl
showing
treatment
results
dental models were negative. It was also found to be virtually impossible to obtain reliable data from cephalograms for accurate quantification of observed changes, since a number of technicians were responsible for making the films ; hence, there was a reduction of internal consistency among the experimental population. Discussion
A number of observations can be made after having conducted the present experiment. Foremost, perhaps, is the fact that we successfully worked with children manifesting tongue thrust who were of a younger age than are children who are normally placed into a more classic swallow pattern therapy program. In addition, it is to be noted that patient cooperation may not have been the critical ingredient in the experimental program that it appears to be in a more traditional program. Both of these observations appear to be reasonable, since conscious application of tongue-placement principles is unnecessary when
Volume Number
70 4
Fig. 5. Lateral tionships and
Subcortical
views dental
of dental relationships
approach
to swallow
models of 75month-old boy 6 months after completion
pattern
therapy
425
showing original dental relaof swallow pattern therapy.
neuromuscular facilitation is used; that is, the normal swallowing process, as it is being learned, need not be intellectualized. The lack of a need to consciously control the swallowing procedure in itself seems to contain certain implications: (1) Perhaps tongue-thrust therapy for the mentally retarded can now be a more viable concept than it is under traditional training conditions; (2) further, the use of neuromuscular facilitation may well be applicable in both growth discrepancy and neurologicaly involved patients, both of whom, again, have usually been rejected for therapy under traditional conditions. Selected factors possibly associated with tongue thrust were also studied. These data allow certain additional observations to be made. With regard to the various parameters evaluated, virtually no difficulty with tongue movements was noted. In addition, with rare exceptions, there were no problems with categories indicated as tongue abnormalities. Further, it is of interest to note that of eleven subjects, one boy and five girls could not whistle; this may be associated with a possible social tendency away from girls learning to whistle. In addition, only one subject who was unable to whistle was somewhat younger than the T-year age by which children arc said to be old enough to be able to whistle .4 No subject had difficulty with blowing.
426
Frrlk, Wells, md
Toth
Nine of the eleven subjects had a history of t,humb- or finger-sucking. The mean age at which this activity ceased for four subjects was approximatel60 months. Further, five subjects, with a mean age of 105 months, were reported to suck their thumbs or fingers occasionally at the time this experiment was initiated. Seven of the subjects had a history of mouth breathing; two subjects had an early history of abnormal drooling; and four subjects had an early history of hyperactive gag reflex. It is of further interest to note that four subjects were breast fed to a mean age of 5.62 months, and nine sul)jects were bottle fed to a mean age of 10.1 months. The discrepancy in this total is due to the fact that two subjects went from breast feeding to bottle feeding and two subjects went from breast feeding to a cup. Eight subjects did not use a pacifier; whereas three subjects used a pacifier to a mean age of 28 months. The mothers of six subjects had no objection to a pacifier. In addition, six of the eleven subjects received a mean of 1.7 school years of speech therapy. No subject received speech therapy prior to entrance into school. Speech evaluation at the outset of the experiment indicated that ten subjects had some form of sound-production error, In eight of these ten cases, the error could be associated with oversibilance as a possible function of the dental relationship present at the time of screening. Of these data, three factors appear to be common to the history of the child with tongue thrust: thumb-sucking, mouth breathing, and articulation error. The latter may be explained as a function of the dental relationships2; however, the other two factors seem to be related, at least in part, to the onset of tongue thrust. These findings suggest support of the concept reported by GarlinerY relative to the influence of perioral musculature in addition to tongue musculature in normal deglutition. Additional observations can be made on the basis of having conducted this experiment. Of the total population referred, only two children did not complete the program. The fact that eleven of thirteen subjects remained in a program which extended over what might seem to the patient to be a lengthy period of time may imply that the neuromuscular facilitation approach to swallow pattern therapy requires less cooperation and motivation than is inherent in previously reported therapy programs, Reasons for this may include the fact that the program is not particularly time consuming, nor arc bhe activities either socially unacceptable or acosmetic. Further, the child can ra,ther easily selfadminister treatment, thus eliminating the need for a parent to be totally involved in therapy. It can also be inferred that the relatively brief period of treatment with neuromuscular facilitation appears to contraindicate the possible effect of spontaneous improvement on the swallow pattern. Previous investigators have found that spontaneous improvement occurs until the age of 8 years.2 Such a finding would not appear to be related to the current study.
Volume Nmnber
70 4
&&xwtical
approach
to ~~nllow
pattern
therapy
427
Nine of the eleven subjects showed no regression 6 months after treabnent ended. It would nevertheless appear necessary to direct attention to the two sub jeets who did manifest some regression. Such regression may have bcm prevented if a partial program of reinforcement had been used during the second 6-month period during which no treatment was administered. Such a J’roctldur( would be consistent with results of other human learning experiments.’ Sum’mary
The neuromuscular facilitation technique was experimentally used with tongue-thrust patients in order to examine the results of application of this technique to such a population. Four boys and seven girls with a mean age of 116 months were referred by orthodontists in the greater Detroit area to Children’s Hospital of Michigan. Each had previouslp been diagnosed as mani-festing tongue thrust. Brushing, icing, and pressure were applied in a home training program fol 6 months. Serial dental models were made at 0, 3, 6, and 12 months, the latter* being used to detect regression 6 months after termination of the therap) regimen. Results are presented to support the contention that neuromuscular facilitation is a useful technique in swallow pattern therapy. Ancillary findings arc’ presented which support the contention that mouth breathing and thumb and finger-sucking precede the onset of tonguo thrust. REFERENCES
1. Doerfler, L., and Stewart, K.: Malingering and psychogenic deafness, J. Speech Hear. Disord. 11: 181-186, 1946. 2. Fletcher, 8. G., Casteel, R. L., and Bradley, D. P.: Tongw thrust swallow, speech articultition, and age, J. Speech Hear. Disord. 26: 201-208, 1961. 3. Garliner, D.: Myofunctional therapy in dental practicr, Brooklyn, 1971, Bartel Dental Rook Co., Inc. 4. Gesell, A., and Ilg, F. L.: The child from five to ten, Nex York, 1946, Harper & Rrothers. 5. 11~8, J.: Application of the Rood techniques to treatment of the physically handicapped child. In West, W. L. (editor) : Occupational therapy for the multiple handicapped child, Chicago, 1965, University of Illinois. 6. Moore, J. C.: Neuroanatomical and neurophysiological factors basic to tile use of neurw muscular facilitation techniques. In West, W. L. (editor) : Occupational therapy for the multiply handicapped child, Chicago: 1965, University of Illinois.