Whistle and Horns as Therapy Tools

History and Function

Horns or whistles have been used for thousands of years for spiritual, practical, and entertainment purposes. Originally they were simple devices that produced sound when air was forced through an opening.

Whistles were mainly made of bone or wood. One of the most distinctive whistles is the boatswain's pipe used aboard naval vessels to issue commands and salute dignitaries. It has evolved from pipes used in ancient Greece and Rome to keep the stroke of galley slaves. A medieval version was used during the Crusades to assemble English crossbow men on deck for an attack. Their loud, attention-getting blast made whistles essential for police officers and sports referees.

The modern era of whistle use began in 1878 when a whistle was first blown by a referee during a sporting event. Hudson, a toolmaker who was fascinated with whistles, fashioned a brass instrument that was used in a match at the Nottingham Forest Soccer Club. This device was found to be superior to the usual referee's signal of waving a handkerchief.

Horns originally were made from animal horns and primarily used as signaling devices. One of the earliest "horn-like" instruments, the lur, dates back to sixth century B.C. Made of bronze. These horns were used on the battlefields by Scandinavian clans.  It makes a loud, obnoxious sound, just perfect for striking terror into the enemy camp. The horn as a musical instrument has only existed for several hundred years.

In Europe, horns gained popularity in the trendy sport of hunting. As this aristocratic sport spread, horn-makers experimented with different shapes and sizes to increase the range of notes possible.  In 1636, French musical scholar Marin Mersenne wrote of four different kinds of horns in his Harmonie Universelle: Le grand cor (the big horn), the cor à plusiers tours, (the horn of several turns), le cor qui n'a qu'un seul tour (the horn which has only one turn), and le huchet (the horn with which one calls from afar). Horns such as the cor de chasse and trompe de chasse (pictured left) fall into this latter category.

In the modern days we use horns and whistles not only forgetting attention, hunting, or entertainment purposes but also as a very effective therapy tool. The speech therapists utilize them to correct articulation disorders, deal with deficits in phonation or breathe control, work with cleft palate repairs, teach velopharyngeal functions and improve speech clarity. Using horns as therapy devices is not only powerful, but most of all fun. When you use horns or whistles you deal with the development of muscles in three areas and in specific order: phonation through the abdominal muscles, resonation through muscles of the velum and articulation via the muscles in the jaw, lips and tongue. Traditional speech therapy without the proper muscle control cannot be completely successful, but it is equally important to remember that oral-motor therapy is an adjunct to traditional therapy, not a replacement. It is critical that clinicians not stop or replace their clients' current therapies in favor of oral-motor therapy, rather that they use it as an additional building block. When the targeted muscles do normalize, the introduction of traditional methods such as auditory feedback, or phonological processing approaches, attain measurably higher degrees of success.

Horn Therapy after Sara Rosenfeld-Johnson

Sara Rosenfeld-Johnson, M.S.,CCC/SLP, an oral-motor guru, has developed a program that includes fourteen progressively more complex horns. I personally attended the training led by the master and since then I’ve been often using the whistles, known also as horns.

Sara Rosenfeld-Johnson designated specific goals such as:

• correcting an interdental lisp,
• improving lip-rounding,
• working on specific phonemes.

She distinguished two broad categories of clients:

1. Clients with more severe problems, who start at the first horn and work to complete the entire hierarchy. These clients must successively master each horn until they reach horn fourteen, the final horn. This approach is suitable for the clients with Cerebral Palsy or Down Syndrome and could take up to two years.
2. Clients with less severed problems, whose specific needs can be treated by the use of individual horns that work on their personal speech deficits. This gives the clinician a methodic, scientific way to create an individualized program for each client that often is completed in four to five months. These exercises can be used by clients of all ability and age groups starting as young as eighteen months. In a few instances I have used them with clients as young as twelve months and had success with a client one hundred-four years old!

She put some facts under the following consideration:

• Clients who present lack of grading in only a jaw, tongue or lip are counted as the least impaired patients.
• Clients who have deficiencies in velopharyngeal closure must address those defects before the jaw, tongue or lip issues are addressed.
• Clients with abdominal deficiencies are considered the most severely impaired. In that case the jaw, tongue and lips cannot be addressed until the velum is addressed, and the velum cannot be addressed until the abdominal control for airflow is addressed.

Sara Rosenfeld-Johnson organized the horns by goals and the muscle movement required to produce phonemes. Not to repeat what was already said I will quote her article published on May 31, 1999 in ADVANCE Magazine.

”Each horn incrementally becomes a degree harder when working in the hierarchy, rechallenging the client's achievements in a rewarding way. They are suitable for group therapy environments, like those with school children, and some can be adapted to create interest for visually impaired clients. Horns are also an important part of a drooling program because they address awareness of lips, maintenance of lip closure and teach retraction of saliva back over the tongue, much of which can be taught without cognitive cooperation. With horn therapy even our clients with major deficits make significant therapeutic progress.

At the outset of the program, after diagnosis, the therapist introduces a target horn and determines the highest number of repetitions that can be achieved in rapid succession at one time without a break. The goal with each horn is to achieve twenty-five successive repetitions, taking a small breath between each blow. If the maximum number of repetitions produced is less than the targeted goal of twenty-five the therapist stops there and assigns the attained number as homework to be practiced each day. These exercises should be practiced at least twice a week with the therapist and, ideally, at least once a day at home. As each horn is mastered, the therapist introduces either the next horn in the hierarchy or the next horn appropriate to the client's goals. Parents and caregivers assist the client to practice their homework. As we know, it is vitally important that parents/caregivers be assigned a meaningful role in treatment. Many of our young cognitively impaired patients can barely interact with their parents. Involvement in this homework gives them an easily fulfilled assignment that gives immediate emotional and therapeutic feedback for the child and the parent/caregiver.

Let's briefly review a few specific horns to better understand their interaction in the hierarchy and discuss some of their unique attributes.

1. The first horn is so easy that it requires almost no abdominal constriction and no constriction of the obicularis oris muscle. It produces sounds almost from the client's vegetative breathing. This horn teaches jaw elevation with minimal lip closure as the client learns to volitionally control airflow. Outside of the hierarchy it improves the production of the sounds /m, b, p /.
2. The second horn is a harmonica-like device that teaches further lip closure and the skill of projecting exhalation in a frontal manner. By gradually covering up the side holes until only the central holes remain exposed, clients can feel (and hear) the redirecting of airflow to the very front of the lips. Used alone, this instrument works on the standard production of /s / by assisting in the correction of a lateral lisp.
3. The third implement is similar to a slide whistle. It requires more than elementary lip closure and teaches first level lip rounding for the production of /w, oo, sh, ch, j /.
4. The fourth horn has a flat mouthpiece and must be blown for a one-two second duration. These variations increase the abdominal and lip closure difficulty, furthers the work on production of /m, b, p / and the prolongation of oral language statements.
5. The horns five, six and seven address additional prolongation of sound, bilabial sounds, oral-tactile defensiveness and low jaw sounds required for vowels and open-mouth consonants. Horns eight and nine work on bilabial sounds and tongue retraction. Horn nine is also an important tool for clients working on oral-nasal contrasts, especially after cleft palate repair.
6. Horns ten through fourteen work on intensifying the degree of duration of exhalation, lip-rounding, lip protrusion, tongue retraction/release, abdominal constriction/tension and they specifically target the correction of the interdental lisp.

As we said horns are fun, and fun is a motivator. Part of the success of this therapeutic approach is that this is work, and for many clients, difficult work. The work is disguised as a toy and the fun that they have repetitively using the toy is exercise, the same as doing ten, twenty or thirty sit-ups is exercise. Recreating a muscle movement through the element of repetition is our goal with each horn used. But keep in mind that this is not play therapy, this is work!

Accordingly there are certain rules that must be followed during therapy:

1. Whether an adult or a child, the client's feet must be firmly on the floor, or other stabilizing surface, and the body should ideally achieve 90° angles in the pelvis, knees and ankles. This does not vary whether your client is in a chair, a wheelchair or you are working with them over therapy balls, bolsters or in a prone-stander. The importance of posture during these exercises cannot be overstated. Stabilization in the body allows for mobility in the mouth. Seating and posture are so imperative that I encourage you to consult with a physical or occupational therapist to achieve optimal or maximal positioning. This postural work has been traditionally in their realm, but for the purposes of these exercises it is now ours, too. During all of your therapy sessions with the client, and during homework, it is important to maintain this maximal posture.
2. The therapist holds the horn and makes sure that there is no biting, because if these horns are used incorrectly they will become toys and rendered ineffective for therapy. If a therapist were to simply hand a child the horn their first reaction would be to put it into their mouth and bite on it. Biting eliminates the therapeutic jaw-lip-tongue dissociation component of horn therapy. Beginning with the ninth horn clients who are cognitively involved with the therapy and who show that they are capable of following directions can be allowed to hold the horns by themselves while the therapist continues to monitor posture and placement. For older children and adults, therapists should use their discretion based on diagnosis and cognitive ability.
3. Remove the horn from their mouth after each blow. This therapy requires repetition. We are recreating muscle movement over and over again to develop strength/muscle memory. The goal with each horn is to be able to blow, with controlled exhalation, twenty-five successive repetitions and for the jaw, lips and tongue to successfully reposition prior to each blow.

The client populations who benefit from these techniques are truly diverse. For example, clients who have the diagnosis of apraxia/dyspraxia can use horn therapy to learn motor-planning movements for the eventual development of speech clarity. These methods sidestep their deficiencies. The stimulus-response technique of the horn creates the muscle action allowing the muscle to take that movement into memory. A clinician can put their hand on a client's stomach and push inward during an exhalation getting the air to go through the horn and produce sound. This gives the client a new awareness of the fact that something that happens in their abdomen creates sound from their mouth. Cognitively impaired clients gain this same awareness devoid of verbal instruction.

Many clients of various diagnosis have insufficient ability to contract and grade their abdominal muscles and must learn to tighten them in order to control their exhalation. Low tone in their abdominal muscles produces insufficient amounts of air that only support single words or short phrases. Horn therapy assists to accomplish this without using compensatory skeletal movements such as shoulder elevation and/or whole body tightening. These are just two kinds of clients whose problems have not been adequately addressed by traditional speech therapy. The result has been a significant inhibition of the client's ability to express themselves at their cognitive level. At the completion of the horn therapy program, whether using the complete hierarchy or a therapist prescribed progression of specific horns, we have clients with the adequate strength and mobility to start traditional articulation therapies, including auditory feedback and the phonological approach - and they got to make a little music along the way.”

Resources:

History about whistles:
http://www.madehow.com/Volume-4/Whistle.html#ixzz2XO3AVAoy

Talk Tools, company founded by Sarah Rosenfeld Johnson http://www.talktools.com/

Horn Kit http://www.talktools.com/original-horn-kit/