Ask A Therapist: Adult Patients with Velopharyngeal Closure
An SLP working with adult stroke patients asks how to incorporate horn therapy for velopharyngeal closure. Sara Rosenfeld-Johnson explains the two-phase OPT approach: building supported oral airflow through the Horn Hierarchy first, then advancing to Oral-Nasal Contrasts for direct velar mobility work.
SRJ
Sara Rosenfeld-Johnson, MS, CCC-SLP
Founder, TalkTools
4 min read
Key Takeaways
The Horn Blowing Hierarchy develops supported oral airflow and is the prerequisite for direct velar mobility work in adult patients with VPI.
"Oral-Nasal Contrasts" is the primary exercise for improving velopharyngeal closure. It is introduced only after the horn hierarchy establishes foundational oral airflow control.
The Horn Hierarchy is not a standalone treatment for VPI, but the first phase of a structured OPT approach to velopharyngeal work.
OPT for adults with VPI follows the same hierarchy progression as pediatric treatment, adjusted for the adult client's motivation and learning style.
Quick Answer
For adult patients with velopharyngeal insufficiency (VPI), including stroke survivors, the OPT approach uses a two-phase sequence: first, the Horn Blowing Hierarchy builds the supported oral airflow and abdominal grading that are prerequisites for velopharyngeal work; second, the "Oral-Nasal Contrasts" program directly targets velar mobility and closure. Full step-by-step instructions for both phases are available in Oral Placement Therapy for Speech Clarity and Feeding by Sara Rosenfeld-Johnson.
Reader Question
From a Reader
Hello, I am a Speech Pathologist from the Pittsburgh area. Could you tell me what you use as far as horns so that I may incorporate them into my therapy sessions. I see stroke patients who have issues with velopharyngeal closure, and wanted to try your techniques. Thank you so much!
Understanding the Two-Phase OPT Approach to VPI
Velopharyngeal insufficiency (VPI) in adult patients, including those recovering from stroke, requires a staged treatment approach. The Horn Hierarchy and the Oral-Nasal Contrasts program are not used simultaneously but in sequence, each building on the other.
Phase 1
Horn Blowing Hierarchy
Develops supported oral airflow and abdominal grading. This is the foundational prerequisite that must be established before the velum can be directly targeted. Cannot be skipped.
Phase 2
Oral-Nasal Contrasts
The primary exercise for improving velopharyngeal closure. Teaches the velum to differentiate and control nasal vs. oral airflow. Introduced only after Phase 1 oral airflow control is established.
Clinical Insight
Without the foundational oral airflow established by the Horn Hierarchy, the velum cannot effectively learn to distinguish between nasal and oral airflow during Oral-Nasal Contrasts. The sequencing is not optional. It is the mechanism that makes Phase 2 effective.
Therapist Answer
Sara Rosenfeld-Johnson, MS, CCC-SLP
Hi, Your email came at a very good time as I am just finishing my new book on using Oral Placement Therapy with adults. One of the chapters addresses the issue of VPI and how horns can be used in a hierarchy to improve mobility in the velum. The Horn Blowing Hierarchy develops a supported oral airflow and is a pre-requisite for direct work on velar mobility.
The real way to improve closure is by using the exercise called "Oral-Nasal Contrasts." Although the book will not be published for at least six months you can learn about these activities in my first book Oral Placement Therapy for Speech Clarity and Feeding. That book would give you the step-by-step instructions for how to progress through the horns and then how to implement the "Oral-Nasal Contrasts" program. I hope this has answered your question but if not please feel free to email me again.
Sara Rosenfeld-Johnson, MS, CCC-SLP, Founder, TalkTools
Using the Horn Hierarchy for Velopharyngeal Closure in Adults
Follow this sequence when incorporating the Horn Hierarchy into treatment for adult patients with VPI or reduced velar mobility:
Assess the client's velopharyngeal function, nasal air emission, and oral airflow to establish a baseline before beginning.
Introduce the Horn Blowing Hierarchy, starting with Horn #1, to develop supported oral airflow and abdominal grading. These are the foundational prerequisites for velopharyngeal work.
Progress through the horn hierarchy in sequence. Each horn builds on the controlled exhalation established in the previous stage. Do not advance until the client meets the criterion for each level.
Once the client demonstrates consistent oral airflow through the hierarchy, introduce the "Oral-Nasal Contrasts" program to directly target velar mobility and closure.
Monitor progress in velar mobility and reduced nasal air emission during speech. Adjust horn level and pacing to match the adult client's learning rate and motor capacity.
Clinical Note for Adult Stroke Patients: OPT hierarchy progression is fully applicable to adult clients with post-stroke VPI. Pacing and sequencing should be adjusted to the client's cognitive and motor profile. Adults typically bring strong motivation and metacognitive awareness to the program, which can accelerate progress through the horn hierarchy stages.
The complete 12-horn hierarchy for developing abdominal grading and supported oral airflow, the essential prerequisite before beginning direct velar mobility and Oral-Nasal Contrasts work with adult patients.
Horns develop the oral airflow and abdominal grading needed before direct velopharyngeal work begins. Closure is primarily improved through the Oral-Nasal Contrasts program, which should follow horn hierarchy mastery. Using horns without progressing to Oral-Nasal Contrasts will not produce the velar mobility changes needed for improved closure.
How does the Horn Hierarchy help with VPI?
The Horn Hierarchy builds supported oral airflow, which is controlled exhalation through the mouth. This is a prerequisite for teaching the velum to differentiate between nasal and oral airflow. Without this foundational control, Oral-Nasal Contrasts exercises are less effective.
Is OPT appropriate for adult stroke patients with VPI?
Yes. Sara Rosenfeld-Johnson notes that OPT can be incorporated into treatment for adult clients with post-stroke speech and motor deficits. The hierarchy approach is adapted to the adult client's abilities, with pacing and sequencing adjusted accordingly.
Where can I learn the full protocol for Oral-Nasal Contrasts?
The complete step-by-step protocol is available in Oral Placement Therapy for Speech Clarity and Feeding by Sara Rosenfeld-Johnson, which covers horn hierarchy progression and the full Oral-Nasal Contrasts program.
