Tongue-based manual therapy and sensory receptive preferences
Gentle, patient-informed manual therapy through the oral region has become a mainstay of the work I teach and use. With usages ranging from articulation and feeding difficulties to dysphagia concerns, there is good reason to explore gentle, sustained tongue engagements to improve awareness and sensory motor control. In seminars, we explore a variety of materials to ensure we have adequate “grip” without being intrusive. These materials typically include woven or non-woven gauze, cotton finger cots, and Medipore tape. With proper grip, there is little need to squeeze excessively to ensure engagement and, ideally, a non-threatening therapeutic experience for the patient.
At a recent Introductory seminar, I was called to a working partnership of speech language pathologists who presented me with a dilemma. The clinicians acting as the “patient” defined themselves as autistic and found the texture of the materials objectionable. Having not encountered this scenario, we worked through a few possible workarounds. First, I used methods I will trial with patients who have a hyper-reflexive gag, beginning with a lowering of my voice volume, then by requesting to protrude the tongue to only a small amount, and, finally, slowing the pace of the entire treatment sequence. These steps seemed to positively respond to the “patient”, allowing them to be present with the experience. Next, we discussed having the patient be the one who grasped their tongue, with me working over/through their fingers. Both strategies prevented them from being placed into a threatened situation and fully participating in the exercise. Lastly, we discussed the possibility of allowing the patient to choose the medium used to aid in grip and how this could occur in the clinical setting. If a patient had trouble tolerating the grip materials, I theorized that it may prove successful for them, in their next session, to bring a fabric that seemed less threatening to them, giving them a choice.
There may be instances where no modification becomes tolerable for the individual. In such cases, I would not oppose attempting the work with gloves alone. However, experience has shown that when I don’t have any grip aid, my squeezing of the tongue necessary to avoid slipping becomes nearly painful for the patient. However, with some patience and patient empowerment, you may find success by modifying your typical routine and inserting alternative grip aid choices, allowing the intervention to proceed.
Manual therapy interventions, as I see them, should be completely non-threatening, to allow full acceptance and to build sensory motor changes and choices. Modifying the treatments to enable this acceptance should be paramount to promote these ideals.
Addendum: The individual referenced in this article attended a subsequent Advanced class one week after their first class. They stated that after exploring fabrics at home, none were tolerable to his nervous system. Faced with this status, we explored tongue-based manual therapy and exercise-based work with the clinician (me) using only nitrile gloves. This caused me to reflect on my biases, mainly that a solid and secure grip was needed to perform my work adequately. I was wrong. Though my fingers slipped at times, the sensory input provided, now entirely tolerable, continued to impact the patient’s awareness and proved fully capable of providing input for motor change. So long as we continue to view manual therapy within a box containing only tissue-based impacts based on a sustained stretch, we (and I) will continue to follow our biases. Had I not had the opportunity to expand outside of my box, I would not have learned this lesson. Suppose awareness building is seen as the only key to modifying behaviors and actions. In that case, the sustained pressures provided only by a secure grip, manual therapy will be held inside its secular box. It is time to rip the lid off it and see it for what it is:
“Clinicians should remember that manual techniques are not tools to fix the patient’s body, rather they provide the opportunity to communicate with the patient’s brain similar to words” (Geri et al., 2019, pg. 3).
Geri, T., Viceconti, A., Minacci, M., Testa, M., & Rossettini, G. (2019). Manual therapy: Exploiting the role of human touch. Musculoskeletal science & practice, 44, 102044. https://doi.org/10.1016/j.msksp.2019.07.008
Walt Fritz, PT
Foundations in Manual Therapy: Voice and Swallowing Disorders Seminars
