F.O.T.T. (Facial-Oral Tract Therapy), developed by ARCOS Director Kay Coombes, provides a structured way to assess and treat disturbances in one or more of the following:

  • Facial expression
  • Movement of the jaw for eating and articulation
  • Breathing
  • Swallowing
  • Voice

These difficulties occur in a range of conditions and vary in severity. Used by therapists, nurses and relatives, F.O.T.T is a comprehensive approach, focusing on 4 main areas of nutrition, oral hygiene, non-verbal communication and speech. in the context of the whole body. F.O.T.T. courses are held throughout the UK, mainland Europe, Scandinavia and in Japan. For further information on courses available, please contact ARCOS.

F.O.T.T. principles are based on:

  • a thorough understanding of normal human movement, sensation and learning
  • the ways in which these can be disturbed or distorted
  • careful analysis of difficulties
  • skillfull handling to influence posture, movement and sensation
  • the application of these principles to the particular individual without requiring them to understand speech
  • Therapy fosters learning through how it feels to carry out everyday activities, such as cleaning the teeth, eating and drinking (or being fed), rather than by “exercises”. Progress is monitored and evaluated.

The goal of therapy is to prevent the accumulation of symptoms, reduce disability and avoid handicap as far as possible, build confidence and enable individuals to become as comfortable and independent as possible. Careful attention is paid to the entire sequence of an activity from initiation, including getting ready to do something, to completion of the task.

Therapy is designed to re-establish appropriate sensory feedback from the patient’s own body because this is the route to independent function in those with subtle difficulties, as well as dramatic symptoms found in individuals with severe brain injury. Early intervention for those in coma, aims to prevent the effect of sensory deprivation which contributes to hypersensitive (“defensive”) responses. These include intolerance of touch, withdrawal and bite-reflex. Treatment methods include slow, organised touch of the individual’s hands, facilitating hand-to-hand and hand-to-face contact, together with specific oral stimulation, therapeutic oral hygiene routines and facilitation of swallowing.

The sequence of normal swallowing – a complex process

Normal swallowing is a smoothly coordinated process. Four stages or “phases” are identified and these are conventionally labelled “pre-oral”, “oral”, “pharyngeal” and “oesophageal”. The pre-oral stage is one of readiness for biting, chewing and pharyngeal swallowing. It involves anticipatory saliva production in response to seeing and smelling food or drink, and bringing it to the mouth independently in self-feeding. These important operations “set the scene” for the oral stage, which comprises bolus formation and transport, lubricated with saliva, to the back of the mouth so that it can be delivered into the pharynx (throat). Each stage influences subsequent stages. Thus, in-coordination of the oral stage affects the timing and co-ordination of the pharyngeal stage, even when the pharyngeal reflex remains intact. Recognised influences on swallowing include body posture as well as breathing.

In what ways can this sequence be disrupted and how can F.O.T.T. help?

Alignment of the body and dynamic stability are often dramatically changed in neurological conditions such as cerebral palsy, stroke, M.S. or head injury. For example, the trunk may be rounded, the head translocated forward in a compensatory pattern of extension and this is likely to lead to a similar pattern of extension in the face. So, if the neck is hyper-extended, the forehead is often raised as part of the extension pattern and the jaw is depressed and retracted; the mouth is typically open, with retracted lips exposing the gums and teeth. Impairment of tongue movement is exacerbated by this pattern which inhibits selective tongue movement, because of the way in which it encourages retraction of the tongue (as part of the extension pattern).

Without careful handling to facilitate more normal tension (tonus) in the muscles and appropriate response to sensory input, such an individual is likely to demonstrate intolerance of touch (tactile input). This is manifested by hypersensitive and stereotypical responses such as a bite reflex which makes oral hygiene difficult and functional movement impossible.

“The face, mouth and hands are rich in sensation and afford enormous possibilities for sensori-motor learning, given appropriate input and an adequate background posture.” (Kay Coombes)

Click here to go to the F.O.T.T Special Interest Group website, designed to encourage the sharing of best practice.