Possibilities in Neurogenic Stuttering Treatment - Home - ECSF

Dr. Kathrin König ▪ Speech language pathologist ▪ Bochum ▪ Germany ▪ [email protected]

Possibilities inNeurogenic Stuttering Treatment

An empirical study on

therapists` experiences


„Stuttering is more than a riddle. It is at least a complicated, multidimensioned jigsaw puzzle, with many pieces still missing”

(Van Riper, 1982, 1).

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1. Definition and etiology

Presentation agenda

2. State of research in literature

3. Research questions

4. Empirical study and methodology

5. Findings

6. Conclusion






5. Findings

6. Conclusion

Presentation agenda


Occurence of symptoms for the first

time in life or

massive change or aggravation of existing

stuttering pattern

Diagnosis of a neurological disturbance or underlying disease

Speech dysfluencies in the form of repetitions, prolongations and/or

blocks

Direct correlation between the neurological disturbance and the onset of speech dysfluencies Possible onset at

any age

Neurogenic Stuttering

According to: Van Borsel et al. (1997) Grant et al. (1999), Leder (1996), Helm-Estabrooks (1986)

Definition


▪ Cerebrovascular disease▪ Head trauma/ traumatic brain injury▪ Neurodegenerative disease ▪ Tumor▪ Epilepsy▪ Intoxication▪ Neurosurgery▪ Other diseases of the central nervous system

Etiology






5. Findings

6. Conclusion

Presentation agenda


„Acquired stuttering in adults has received little attention relative to that given developmental stuttering“(Marshall & Starch, 1984, 87).

„Extensive research has been conducted in the field of developmental stuttering, and many facts about this disorder are well documented in the developmental stuttering literature. An equivalent body of knowledge is not available in the area of neurogenic stuttering [...]“(Ringo & Dietrich, 1995, 117f.).

State of research


▪ Limited number of publications

▪ Single case studies

▪ Lack of empirical (group) studies

Critique:

▪ lack of objectivity of studies

▪ lack of comparability of data

▪ inaccurate sampling procedure

State of research


▪ Increased demand for research in the area of neurogenic stuttering treatment

▪ Highly discrepant hypothesis

„Our therapy experience with adults with neurogenic stuttering has been very encouraging. [...] in a good many cases we have seen the stuttering problem completely eradicated” (Canter, 1971,143).

„Results have rarely been dramatic and not always encouraging“ (Rosenbek, 1984, zit. n. Baumgartner & Duffy, 1997, 91).

„The call for more systematically collected data is long overdue“(Curlee, 1995, 125).

State of research






5. Findings

6. Conclusion

Presentation agenda


▪ Which factors evoke a good prognosis?

▪ Is neurogenic stuttering treatable?

Research questions

▪ How is neurogenic stuttering currently treated in Germany?






5. Findings

6. Conclusion

Presentation agenda


§Sampling procedure:

Random sampleTwo-stage sampling procedure:Stage 1: Therapists (cluster)Stage 2: Clients

§Period of examination:

4 years (1.08.2004 – 1.08.2008)

§Research tool:

Structured questionnaire (30 questions: 178 items)

§Research method:

Written survey of 700 speech language pathologists in Germany

Empirical study and methodology


Core symptoms, secondary behaviors etc.

Age, gender, handednessDemographic data

Symptoms

Individual aims

Medical history, neurological disturbance etc.Etiology

Therapy targets

Fluency shaping or modification techniques

Stuttering therapy, general speech therapy etc.Type of treatment

Focus of treatment

Improvement, aggravation, difficulties etc.

Learning, adopting and transferring techniquesResponse to treatment

Treatment outcome

Questionnaire – subject matters


§Cognitive interviews§ n = 7 therapists

different occupational groupsdifferent therapy setting

Phase 1: cognitive pretest

§Written survey§ n = 100 therapists

§Split-ballot procedure

Phase 2: field pretest (pilotstudy)

assure manageability of the questionnaire andcorrect understanding of questions

avoid ambiguity

Two stage Pretesting (Prüfer & Rexroth, 2000)

Pretest


Follow-up

Informationletter on the upcoming survey

added by: ▪ correspondence letter▪ letter of recommendation

from the faculty ▪ stamped self-addressed

envelope

Contacting the non-respondersby phone

Data collection and data preraration with SPSS 17.0

Pre-informationQuestion-

naireData

analysis

Data collection


Return rate (n = 700)

89 therapists (12,7%) have treated one or more clients with neurogenic stuttering

68 case descriptions (9,7%)

after plausibility check: 61 data sets (8,7 %)

34,0%

53,3%66,0%

12,7%

Response

No Response

Neurogenic stuttering clients among the clientele

No neurogenic stuttering clients among the clientele

Return rate






5. Findings

6. Conclusion

Presentation agenda


Bar chart – age (n = 52)

range: 8-87 years

mean: 55.4 years

standard deviation: 17. 4 years.

Results – age

age (years)

n


Accompanying speech disorders (n = 60)In three fourths of all cases neurogenic stuttering clients showed accompanying speech disorders.

In every second case the client had aphasia.

20,0% 51,7%30,0%

21,7%

21,7% 3,3%

24,6%

Aphasia solely or in combination with other speech problemsNo accompanying speech problems

Apraxia of speechDysarthriaOther speech problemsAphasia (solely)

Aphasia and other speech problems

Results – accompanying speech problems


70,5% 60,7%47,5% 47,5% 32,8%

27,9%13,3%

0%

20%

40%

60%

80%

IrritationDifficulties in handling communication situationsLinguistic avoidance behaviorSituational avoidance behavior

Accessory movementsAnxietyOthers

Secondary behaviors (n = 61)

95.1% of all patients showed secondary behaviors

Results – secondary behaviors


Huge variety of different types of treatment

Average: use of 3.21 types of treatment (sd = 1.07)

Specific stuttering therapy as the most used type of treatment

Type of treatment (n = 61)

18,0%

90,2%

59,0% 52,5% 49,2%45,9%

4,9%0%

20%

40%

60%

80%

100%

Specific stuttering therapyBreathing exercisesMotor speech therapy/facial exercisesAphasia therapy/word finding exercisesRelaxation techniquesOther types of treatmentMedical treatment

Results – Chosen type of treatment


Stuttering modification

n Fluency Shaping n Speech devices n

Easy onset 30 Slowing speech rate 37 Metronome 11

Easy syllable repetitions

21 Rhythmical speech 37 Chorus speaking 9

Easy articulatory contacts

15 Continous phonation 5 Shadowing 7

Cancellation 14 Prolonged speech 5 Pacing Board 5

Use of starting sounds 9 Biofeedback 1

Pull-out 8 Other fluency shaping techniques

3 Delayed auditory feedback

1

Other modification techniques

2 Other speech devices

3

Type of stuttering treatment (n = 54)

Results – Specific stuttering therapy


2

1

1

1

1

11

10

1

1

2

9

2

0 2 4 6 8 10 12

Pacing Board

Metronom

Prolonged speech

Continous speech

Slowing speech rate

Rhythmical speech

Other modification technique

Easy syllable repetitions

Use of starting sounds

Easy onset

Cancellation

Oth

ersS

peec

hde

vice

sF

luen

cyS

hapi

ngS

tutt

erin

gm

odfic

atio

n

Results – Core techniques

Focus of stuttering therapy (n = 42)


Psycho-social methods (n = 56)

94,9% of all therapists used psycho-social methods

Results – Psycho-social methods

14,0%

55,4%

58,2%

70,4%

90,9%

0% 20% 40% 60% 80% 100%

Other psycho-social methods

In-vivo training

Counseling of relatives

Anxiety reduction

Information on stuttering


Achievment of therapy target

CRITERIA

OF

SUCCESS

Improvement of speech (improvement of body functioning)

Improvement of psycho-social factors (activity and participation, positive affect on context factors)

Results – „Success“ of treatment


35,7%

8,9%5,4%

42,9%

7,1%

0%10%20%30%40%50%

not ach

ieved

(0)

rudim

entary

(1)

partly

(2)

widely (3

)

entire

ly (4

)

Degree of target achievement

No significant difference between the 3 superordinate targets of treatment with regard to the degree of target achievement (χ2 = 1,429; p = 0,489).

35,6%

37,3%

27,1%

reduction of core symptoms

appropriate handling of stuttering

improvement of general linguistic skills

Overall target of treatment

Results – Achievement of therapy target


29,5%

21,3%0,0%

21,3%

not possibleconditionally possiblegoodexcellent

Acquisition of the chosen speech technique (n = 44)

45,2%31,0%

16,7% 7,1%

not possibleconditionally possiblegoodexcellent

Use of the chosen technique in spontaneous speech (n = 42)

Comparison of speech techniques:

Easy onset, rhythmical speech, slow speech rate

No significant difference between the 3 techniques with regard to acquisition (χ2 = 0,421; p = 0,814) and use in spontaneous speech (χ2 = 1,668; p = 0,434)

Results – Improvement of speech


Acquisition

Use in

spontaneous

speech

Acquisition

r 1,000 ,635**

Sig. (2-sided)

,000

n 44 42

State of health

r -,308* -,143

Sig. (2-sided)

,045 ,372

n 43 41

Motivation

r ,542 ** ,519 **

Sig. (2-sided)

,000 ,000

n 44 42

Correlation matrix – Acquisition and use in spontaneous speech

* sig. 0,05 level **sig. 0,01 level

The speech technique was acquired best, in cases of

▪ good state of health

▪ high therapy motivation (of the patient)

The use in spontaneous speech was best, in cases of

▪ an excellent acquired technique

▪ high therapy motivation (of the patient)



Improvement in different speech situations

No significant differences between speech techniques

▪ Improvement in therapy setting: χ2 = 0,391; p = 0,572▪ Improvement in everyday life: χ2 = 1,395; p = 0,238▪ Improvement in stressful situations: χ2 = 0,043; p = 0,836

excellentimprovement

goodimprovement

slightimprovement

noimprovement


Comparison of speech techniques:

Easy onset, rhythmical speech, slow speech rate

improvement in improvement in improvement intherapy setting everyday life stressful situations


therapy setting everyday life stressfull situations

acquisition r 0,632** 0,515** 0,425*

Sig. (2-sided) <0,001 0,003 0,015

n 32 32 32

use in spontaneous speech

r 0,461** 0,545 0,487**

Sig. (2-sided) 0,009 0,002 0,005

n 31 31 31

motivation r 0,347* 0,576** 0,513**

Sig. (2-sided) 0,019 <0,001 <0,001

n 45 45 44

Improvement of speech in different speech situations is correlated with

▪ the factor „acquisition“▪ the factor „use in spontaneous speech“▪ the factor „therapy motivation“

**sig. 0,01 level * sig. 0,05 level



MOTI

VATI

ON

improvement in therapy setting

improvement in everyday life

improvement in stressfull situations

ACQUI

SI

TI

O

USE

Transferring practiced skills



16,4%83,6% 18,5%

81,5%

81,5%18,5%

More participation in communication situations

NoYes

25,5%74,5%

Self-confident handling of stuttering

Reduction of negative impact of stuttering on everyday life

Results – Improvement of psycho-social factors

Reduction of psychological strain


Reduction of psychological strain

More participation in communication situations

Reduction of negative impact of stuttering on everyday life

Selfconfident handling of stuttering

Reciprocal conditionality of psycho social improvement

significant correlation between different apsects of psycho-social improvement.

Results – Improvement of psycho-social factors


19,6%

3,6%

1,8%75,0%

improvement of speech and psycho-socialfactorsimprovement of psycho social factors (solely)

improvement of speech (solely)

no improvement

Improvement of speech and psycho-social factors (n = 56)

inhibiting factors:

▪ bad state of health

▪ lack of motivation

▪ irregular attendance of therapy i sessions

Results – treament outcome


significant improvement over the period of treatment:

▪ psycho-social ..improvement

▪ speech ..improvement

▪ better state of ..health

(p < 0,001)

negativ

positiv

Results – treament outcome

statestate

ofof

healthhealth

severityseverity

ofof

stuttestutte--

ringring

severityseverity

of of

psychopsycho--

logicallogical

strainstrain

negativenegative

impactimpact

onon

everydayeveryday

lifelife

initial condition final conditioninitial condition final condition

statestate

ofof

healthhealth

severityseverity

ofof

stuttestutte--

ringring

severityseverity

of of

psychopsycho--

logicallogical

strainstrain

negativenegative

impactimpact

onon

everydayeveryday

lifelife






5. Findings

6. Conclusion

Presentation agenda


Easy onset

Rhythmical speech

Slowing speech rate

▪ Similar methods as in developmental stuttering therapy can be used

▪ A combination of multiple speech techniques is most often used

Conclusion

▪ Specific stuttering therapy is often supplemented by other approaches

most most frequentlyfrequently

usedusedtechniquestechniques


▪ Demand: treatment has to be based on the patients` indiviudal needs

Strengthening the patient`s motivation

Supporting transfer into various speech situations

Learning and using an exact speech techniquePracticing

Motivation

Transfer

Conclusion

▪ Improvement of speech and psycho-social factors in the majority of cases


„Patients with acquired stuttering – just as those with developmental stuttering – deserve to receive the best evidence-based fluency intervention“(De Nil, Jokel, Rochon, 2007, 327).

Research desideratum

Prospect


Thank you very much for your attention!


Acknowledgement

Special thanks go to:

My parents Heinrich Ulrich König und Ursula König

Univ.-Prof. Dr. Gregor DupuisUniv.-Prof. Dr. Nitza Katz-Bernstein

Marcus Beckmann, Friedhelm Därmann, Anika Förster, Claudia Gerrlich,Maren Gezemba, Stefan Göthel, Robert Hammelmann, Stefani Holland,Matthew Kishinami, Jürgen Lamberti, Karolin Schäfer, Kathrin Sundermann,Alexander Sommer, the statistical center of the University of Dortmund and toall participants in the survey of this study.


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References


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I`d be happy to send you the bibliography. Please feel free to cI`d be happy to send you the bibliography. Please feel free to contact me at my email address.ontact me at my email address.

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