A Preliminary Study Investigating the Effects of a Modified Yoga Breathing Program With Four Individuals Who Stutter

Transcription

1 A Preliminary Study Investigating the Effects of a Modified Yoga Breathing Program With Four Individuals Who Stutter Selene Gatzonis Renee Fabus Adelphi University. Garden City, NY S tuttering is a complex disorder that can have detrimental effects on an individual s physical and emotional states, impacting their functioning in social or occupational situations. The consequences of stuttering can lead to avoidance behaviors in various speaking situations (e.g., in a classroom or a job interview). The International Classification of Functioning, Disability and Health (ICF; World Health Organization, 2001) provides a framework to classify stuttering and its impact on the individual. The ICF states that individuals who stutter may demonstrate a reduced self-perception, thus ABSTRACT: Purpose: This pilot study investigated the effects of a modified Vinyasa yoga breathing program on the fluency skills and self-perception of 4 adults who stutter. The Valsalva hypothesis posits that stuttering is caused by a discoordination between the respiratory and laryngeal mechanisms; therefore, a modified yoga breathing program could be a complementary addition to traditional fluency treatment. Method: Four adults engaged in a 6-week therapy program that included 1 weekly meeting and required home practice. The participants speech was assessed pre and post intervention with the Stuttering Severity Instrument for Children and Adults Fourth Edition (Riley, 2008) and the Overall Assessment of the Speaker s Experience of Stuttering (Yaruss & Quesal, 2006). impacting their quality of life (QOL). The aim of this pilot study was to explore an approach that can be used in conjunction with traditional fluency shaping or stuttering modification to increase the clients speech fluency or modify their stuttering and improve their overall self-perception. Literature Review Yaruss and Quesal (2004) defined stuttering as a speech disorder characterized by interruptions of a conveyed message, resulting in difficulty communicating during Results: Each participant showed an overall decrease in the number of dysfluencies and accessory behaviors. There were no reported changes in the participants self-perception of their stuttering. Several participants reported an increased awareness of their breathing following the yoga program. Conclusions: A modified yoga breathing program can potentially positively impact the fluency skills and decrease the core and accessory behaviors of adults who stutter. Further research is required to examine the long-term effects of such a program with adults who stutter. KEY WORDS: adults, fluency, fluency disorders, intervention, stuttering 246 Contemporary Issues in Communication Science and Disorders Volume Fall 2015 Contemporary Issues in Communication Science and Disorders Volume Fall 2015 NSSLHA /15/

2 daily activities. This definition is framed according to the ICF and suggests that stuttering is a multifaceted impairment including observable atypical speech characteristics, limitations on functional communication, and an impact on QOL. Stuttering involves both body structure and function but can also consist of more than observable behaviors. Stuttering has both immediate effects at the moment of a communicative exchange and long-term effects that may inhibit an individual s future communication. For example, an individual who stutters may choose not to accept an employment opportunity that requires extensive verbal interactions or may avoid social situations in which speaking is required. Although its etiology is largely unknown, stuttering affects all cultures and races, and there may be a genetic predisposition to stuttering (Bloodstein & Bernstein Ratner 2008). Stuttering has a higher incidence of occurrence in males, with the ratio of males to females approximately 3:1 (Shapiro, 2011). Stuttering has been attributed to three major factors known as the 3 ps : predisposition (i.e., genetic factors, such as a family member), precipitating (i.e., environmental factors, such as increased linguistic demands), and perpetuating (i.e., factors relating to chronicity, such as criticism of an individual s speech; Shapiro, 2011). Any of these factors may interact with each other, and it is important to analyze each individual and his or her contributing factors. Core and Accessory Behaviors The central behaviors that are key markers of dysfluent speech are defined as core behaviors (Van Riper, 1982). Williams, Darley, and Spriestersbach (1978) outlined these core behaviors as part-word repetitions; whole-word repetitions; phrase repetitions; prolongations; broken words or blocks; hesitations; interjections of syllables, words, or phrases; revisions; and abandoned or incomplete phrases. Repetitions are most common, with the speaker repeating a single phoneme, syllable, or single-syllable word. Prolongations occur when airflow continues but the movement of the articulators is stopped (Guitar, 2006). Blocks may involve any part of the speech mechanism and occur when a speaker stops the airflow and vocal fold vibration and frequently tenses his or her articulators. Gregory, Hill, and Campbell (1996) defined a hesitation as a silent pause without perceivable tension, with a duration of 1 s or longer. De Andrade (1999) described interjections as a sound, syllable, word, or phrase included in an utterance that is irrelevant to the conveyed message. A revision is a change in content, grammatical construction, or pronunciation of a sentence. Any of these dysfluency markers may be accompanied by decidedly greater than average duration, effort, tension, or struggle (American Speech-Language-Hearing Association; ASHA, 1999). Perhaps as perceivable as the speech dysfluencies are the accessory or secondary behaviors associated with stuttering. These include motor movements such as head turns, mandibular clenching, rapid eye blinks, clenching of the eyelids, and facial grimacing. These movements frequently include tension. Other behaviors associated with dysfluency include laryngeal tension, increased pitch, and changes in respiration immediately preceding or following the stuttering behaviors (Shapiro, 2011). A speaker may use any of these behaviors to avoid the anticipated dysfluencies or compensate for the dysfluent speech. Secondary behaviors have been suggested within several studies to be related to a speaker s self-perception and mental state (Craig, Blumgart, & Tran, 2009; Iverach, Menzies, O Brian, Packman, & Onslow, 2011). Beilby, Byrnes, and Yaruss (2012) found that avoidances are unnatural and burdensome to the speaker. These negative self-perceptions of stuttering decreased the speaker s QOL; thus, other important considerations are the feelings and attitudes that people associate with stuttering. Traditional Treatment Approaches Traditional treatment approaches for people who stutter typically include a combination of fluency shaping and stuttering modification (Guitar, 2006). Fluency shaping focuses on increasing fluent speech by shaping dysfluent speech into more fluent utterances in the treatment session (Snider, 2009; Wan, Rüber, Hohmann, & Schlaug, 2010). These strategies may include easy onset, slower rate of speech, and light articulatory contacts to alter respiration, voicing, articulation, and prolonged speech rate (Curlee & Perkins, 1984; Gregory, 1979; Zebrowski & Kelly, 2002). Manning (2010) found that fluency-shaping techniques could have dramatic results, enabling the client to experience fluent speech in a short period of time. When fluency shaping, the clinician trains the client to take full breaths coupled with slow-prolonged speech to alter the rate of speech, take slower and calmer breaths to alter respiration, and use precise positioning of articulation (Blomgren, Nelson, Callister, & Merill, 2005). Many of these methodologies incorporate breath management principles that are similar to those involved in yoga breathing. Stuttering modification aims to control fluency or produce acceptable stuttering to help an individual to stutter more fluently and with more ease (Zebrowski & Kelly, 2002, p. 39). This technique Gatzonis & Fabus: Modified Yoga Breathing Program and Fluency 247

3 emphasizes reducing negative attitudes and avoidance behaviors that frequently accompany stuttering. Stuttering modification can reduce the rate and tension in stuttering and allow the individual to stutter in a more controlled manner (Guitar & Peters, 2008; Shapiro, 2011). Some strategies include purposeful stuttering, cancellations, pull-outs, and preparatory sets (Zebrowski & Kelly, 2002). This approach targets both the speaker s attitudes and his or her increasing fluency. The individual is able to address both the speech component and the attitudes that accompany stuttering and modify these feelings; however, the rate at which fluency changes often takes longer than other approaches (Shapiro, 2011). Consequently, many clinicians may choose an integration of both fluency shaping and stuttering modification. Self-Perception Sheehan (1970) suggested the iceberg analogy about stuttering where stuttering is deeper than the surface features that are the perceivable behaviors of dysfluent speech. Feelings of anxiety and fear may occur well before speaking situations and can lead to embarrassment, anxiety, difficulty communicating, and a reduced QOL. Repeated instances of negative feelings can evolve into attitudes, and individuals may have negative attitudes about themselves after years of stuttering. The Overall Assessment of the Speaker s Experience of Stuttering (OASES; Yaruss & Quesal, 2006) investigates an individual s self-perception through a series of 100 questions that directly correlate these attitudes with a speaker s daily life. Understanding a client s feelings and attitudes about his or her stuttering behavior may be helpful for making decisions about a client s care (Shipley & McAfee, 2008). Even with the use of techniques and treatment, stuttering can impact an individual s general anxiety levels and overall QOL. Typically, the higher the severity of stuttering, the more negative the impact on an individual s QOL (Bleek et al., 2012; Craig, Hancock, & Tran, 2003). It has been documented that adults who stutter find that their speech restricts life endeavors such as career choice, relationships, and career advancement/promotions (Craig et al., 2009). Craig et al. (2003) conducted a randomized study and found that anxiety levels were high in individuals who stuttered regardless of whether or not they received treatment. Balakrishnan (2009) asserted that the anxiety to stop stuttering can actually create further distress, ultimately leading to increased dysfluencies. Therefore, perhaps treatment should include integrating psychosocial factors with fluency-increasing techniques. Yoga Yoga is a practice that originated in India approximately 5,000 years ago. The discipline combines breathing, improved posture, and meditation to improve an individual s physical condition, calm the nervous system, and balance the body and mind (Barnes, Bloom, & Nahin, 2008). Yoga is acknowledged by the National Institutes of Health (2010) as a mind body medicine. Including yoga in traditional stuttering treatment can provide a balance that is frequently essential to an individual s recovery (Douglass, 2011). The word yoga in Sanskrit is derived from the root yuj, or union (Feuerstein, 2003). There are many forms of yoga, which vary in their execution and targeted bodily systems. According to Uma, Nagendra, Nagarathna, Vaidehi, and Seethalakshmi (1989), extensive studies have shown that yoga can reduce an individual s anxiety and hostility, improve depression, and potentially improve fluency. Yoga addresses many possible anatomical systems associated with stuttering (e.g., respiratory, articulatory, and laryngeal systems). Speech, like yoga, can be regarded as a union of bodily systems to complete a series of movements and convey a message. Yoga enhances posture and respiration, both of which are essential components for speech production (Ristuccia & Ristuccia, 2010). Williams (2010) described respiration as a key feature of a yoga breathing program, which emphasizes the coordination of respiration with movement. Vinyasa yoga works to alter an individual s respiration and breath management by coordinating movements with respiration. Yoga can train the individual to relax the laryngeal muscles so as to reduce tension or strain during speech (Balakrishnan, 2009). Stress and tension reduction is the most prevalent finding in yoga-related research (Douglass, 2011). Cozolino and Sprokay (2006) found that anxiety could hinder left-hemispheric function, affecting an individual s speech and language production. Stress and anxiety frequently occur in individuals who stutter; therefore, yoga may improve both speech fluency and the outlook of the individual. In addition, an important factor in yoga practice is highly structured respiration paired with coordinated movements. Valsalva Hypothesis Parry (2009) proposed the Valsalva hypothesis, which posits that dysfluent speech is a result of interference between the Valsalva mechanism (i.e., muscles of the larynx, chest, abdomen, and rectum) and the respiratory system. Parry postulated that this mechanism is 248 Contemporary Issues in Communication Science and Disorders Volume Fall 2015

4 hyperactive in individuals who stutter, thus leading to a discoordination between airflow and musculature required for the production of fluent speech. Uncontrolled respiration includes inadequate breath support, gasping behaviors, clavicular breathing, and unreleased breath in the larynx during the expiratory process. Respiration, a key component of a yoga practice, can be regarded as disordered according to this hypothesis. Vinyasa yoga offers a solution to this speech discoordination, improving an individual s respiratory and laryngeal coordination through structured movements correlated with corresponding breaths. Connection Between Speech and Yoga Yoga is a practice that aims to increase the coordination between an individual s respiration and musculature through postures, or asanas, paired with diaphragmatic breathing (imperative for speech). We hypothesized that by systematically engaging in a respiratory-enhancing practice, individuals who stutter may improve their respiratory and speech coordination and reduce negative self-perceptions. Hoit and Lohmeier (2000) investigated quiet breathing and breathing during speech in 20 healthy young men. They detected an anomaly in the data, where a participant had a higher tidal volume. They later discovered that the participant was a regular yoga practitioner. Hoit and Lohmeier determined that it is important to recognize that individuals who practice yoga may be more aware of their breathing and may have a tendency to guide their quiet breathing consciously in ways that are preferred. Breathing is a less conscious act, and the speaker can be more focused on the formulation of the spoken message. Pranayama is a segment of yoga that focuses specifically on improving an individual s respiration, in turn increasing his or her awareness of breathing styles and physical functioning (Balakrishnan, 2009; Novotny & Kravitz, 2007). A pranayama technique, which was used in this study, is known as Bhramari, or bee s breath. During bee s breath, an individual produces a vibrating sound with a constant pitch during exhalation while depressing the ear canals. Vialatte, Bakardjian, Prasad, and Cichoki (2008) found that Bhramari changed participants breathing rhythms and reduced their hypertension and anxiety. The participants were observed to have more regular breathing patterns following the Bhramari practice and reported an increased awareness of respiration. There is no literature to date that investigates the use of structured yoga breathing techniques as an additional treatment approach with individuals who stutter. In conjunction with a traditional clinical approach, the clinician can augment traditional intervention by engaging the client in a yoga practice. This study uniquely applies the whole-systems approach to treating stuttering. The aim of this preliminary investigation was to determine if a modified yoga breathing program has any effects on four adults who stutter. This study aimed to answer the following research questions: Does participation in a modified yoga breathing program influence the number and types of dysfluencies in an individual who stutters, as indicated by the participant s scores on the Stuttering Severity Instrument for Children and Adults Fourth Edition (SSI 4; Riley, 2008)? Does participation in a modified yoga breathing program affect the participant s self-perceptions of stuttering according to the OASES scale? METHOD This was a preliminary investigation that included four case studies. All procedures were approved by the institutional review board at Adelphi University. Case studies represent a Level III evidence base in speech-language pathology and were employed because people who stutter are not a homogenous group. It should be noted that this is a preliminary study investigating this topic to determine if further research is warranted. There is no research to date about this topic. Participants Four adult participants, two females and two males, were recruited for this study. They ranged in age from 27 to 39 years and were all professionally employed. The participants all presented with a stuttering disorder and no other speech and language disorders. One participant (Participant 3) was currently receiving speech treatment once weekly. The other participants had received speech treatment in the past but had not received intervention within the past 2 years. The participants were recruited by attending a National Stuttering Association support group meeting where the principal investigator distributed flyers about the study and by word of mouth. The four cases will be discussed in the following paragraphs. The participants consent was obtained prior to initiation of this study. Participant 1. Participant 1 was a 31-year-old African American male who had earned a master s degree and was employed as a college counselor. He Gatzonis & Fabus: Modified Yoga Breathing Program and Fluency 249

5 reported that he had been diagnosed with a stuttering disorder during childhood and that he had received stuttering treatment during childhood and then one instance when he was an adult. He stated that he did not recall what he did in treatment as a child, and he attended treatment sporadically as an adult. He last received treatment for his stuttering in Participant 1 also reported a genetic predisposition to stuttering; both his parents stuttered, but he perceived his dysfluencies as more severe than those of his parents. He reported that his occupation is very stressful, and he had a tendency to stutter during stressful scenarios. During the initial interview, it was noted that the participant exhibited accessory motor movements while speaking, including rapid eye blinks and mandibular clenching. Participant 1 noted that his speech fluency varied day to day, and it was worse in social situations, at work meetings, and during introductions and public speaking. He revealed that his stuttering had improved over the years, and when he stuttered, he attempted to reduce his speech rate, revised what he says, and took extra breaths. He reported no previous experience with yoga. Participant 2. Participant 2 was a 33-year-old Caucasian male who had earned a master s degree and was employed in the finance sector. He reported that he had been diagnosed with a stuttering disorder at age 3 in Russia. He reported that he is fluent in both English and Russian and stutters in both languages. He thought he stuttered because his brain is not working properly. Participant 2 reported no knowledge of any genetic predisposition to stuttering. He received speech treatment in both Russia and the United States but was not receiving treatment at the time of the study. It was noted during the intake that the participant presented with secondary behaviors such as tightening his fists and clenching and squeezing his eyes closed during dysfluent speech. He stated that he avoids all speaking situations. According to the client intake survey, Participant 2 used several strategies to reduce his dysfluencies, including prolongation, cancellation, advertising his stutter, and voluntary stuttering. He had tried hypnosis, seeing a psychologist, and different breathing techniques to reduce his stuttering. Participant 2 reported stuttering more frequently during conversational tasks and in social situations. He stated that he was interested in practicing new techniques such as yoga and meditation to assist with increasing his fluent speech. He indicated that he had experience with yoga but did not attend classes at the time of the study Participant 3. Participant 3 was a 27-year-old African American female who had earned a master s degree and was employed as an actress. She indicated that she had been diagnosed with a stutter during childhood. Participant 3 reported a genetic predisposition to stuttering; her great uncle had a fluency disorder. She indicated that she stuttered more during public speaking and when telling a story. She reported that she actively used voluntary stuttering as a technique to alleviate her dysfluent speech, and she was working with a speech-language pathologist once weekly at the time of the study. Participant 3 reported difficulty with speech during social situations and during acting rehearsals. During baseline data collection, we noted that Participant 3 s secondary behaviors were pronounced. She exhibited pronounced and tense facial grimaces, a trembling and often clenched mandible, and rapid eye blinking. She stated that she had experience with yoga but was not enrolled in any classes at the time of the study. Participant 4. Participant 4 was a 39-year-old Caucasian female who had earned a bachelor s degree and was employed as an architect. She indicated that she had been diagnosed with a stutter during childhood. When she was a child in the second grade, she stopped treatment because her clinician claimed she was cured; however, she resumed treatment at 22 years of age. According to the client intake form, Participant 4 reported that her last speech treatment session was approximately 16 years ago when she was 23. She reported that she was very good at hiding her stuttering. She stated that there is a genetic predisposition to stuttering in her family, but she did not state who in her family stuttered. Participant 4 also reported significant medical history including hypothyroidism, fibromyalgia, and knee and back injuries. She indicated that her stuttering had improved from childhood, but her anxiety has not lessened. She believed that her anxiety about stuttering caused her to tense her throat, upper chest, and neck, so she developed strategies to try to reduce her anxiety. Her techniques were that she tried to relax and speak in song. She avoided words, changed words, slowed down, backed up, and started over. Then, at times, she sped through words. She believed that her stress level affected her fluency from day to day. She believed her stuttering was caused by her introvert personality and that she felt unheard at home and in class. She stated that she stutters more during social situations, speaking in front of a large group, and speaking on the telephone. The participant exhibited mild associated behaviors, primarily clenching tension in her jaw. According to the client intake form, Participant 4 noted that she tended to hold her breath frequently and was currently taking a small dose of clonazepam to alleviate her anxiety. She also reported that she had experience with yoga but was not currently enrolled in any classes. 250 Contemporary Issues in Communication Science and Disorders Volume Fall 2015

6 Materials and Testing Measures The participants completed a client intake form that included questions about each participant s history of stuttering, medical history, previous intervention, and yoga experience. Additionally, we asked the participants to describe any significant medical history as well as their fluency skills in various speaking situations. We administered the SSI 4 to each participant. The SSI 4 is a standardized assessment that analyzes the percentage of an individual s dysfluencies; the durations of the dysfluencies; and the physical concomitants, or accessory behaviors, associated with his or her stuttering. We used these three components to obtain a stuttering severity rating. We also administered the OASES to all of the participants. The OASES provides information on each participant s self-perception, attitudes toward stuttering, and impact on his or her QOL. The second section of the OASES correlates strongly with the S24 scale (Erickson, 1969), which is another selfevaluation tool that provides information about the participant s attitude. The other parts of the OASES provide more information in terms of functional communication differences and improvements in QOL. The evaluation consists of 100 questions about selfperception and attitudes toward dysfluency based on a Likert rating scale. The OASES is scored by calculating the impact score for four subcategories, and the scores are averaged to obtain an overall impact score. The principal investigator designed the yoga sequence that was used in this study The sequence was based on Vinyasa yoga (which is a style of yoga) and focused on coordinating movements with respiration in order to improve the participant s speech. A full list of poses used in the study is provided in the Appendix. The principal investigator also created a home practice video, which was approximately 30 min in length and contained the same yoga sequence for each participant to practice at home. The individual performing the yoga postures in the video was a certified yoga instructor who had no interaction with any of the participants in the study. Yoga mats and other yoga props were provided during the yoga treatment sessions. Procedure The participants were required to complete six weekly yoga sessions at the rate of one per week with the principal investigator for 1 hr (1 60 min) and two half-hour home practice sessions weekly (2 30 min) for a total of 2 hr weekly. During the initial meeting at the yoga studio, the principal investigator completed the pre-assessment with each participant individually. Each participant signed a consent form and completed an intake form. Following the client intake form, a conversational speech sample was elicited and recorded with two recording devices, an M-4 audio recorder and an iphone voice recorder, in order to maximize accurate data collection. To obtain a reading score, we instructed the participants to read a phonetically balanced passage from the SSI 4. Next, to obtain a speech sample, we instructed them to describe a picture from the SSI 4. We then analyzed these samples according to the frequency of stuttered syllables divided by the total percentage of syllables in order to obtain a percentage. The duration of the stuttering episodes was also analyzed. Finally, the accessory motor behaviors that may accompany stuttering, such as eye blinks, facial tension, and grimacing, were also scored according to the guidelines of the SSI 4. The participants then completed the OASES and responded to questions regarding the impact of stuttering on their daily lives. Each participant completed the self-rating scale. This concluded the pretesting. Following the pretesting, the participants engaged in a 1-hr long Vinyasa yoga session. Each pose was verbally explained and demonstrated by the principal investigator, with the corresponding inhalation and exhalation breaths. The poses were presented in the following order during each session: breath awareness, chanting/bee s breath, surya namaskara A, triangle/right angle, tree pose, chair pose, warrior 1 and 2, staff pose, left intense stretch, right intense stretch, seated spinal twist, bridge pose, forward bend, fish pose, supine twist, and savasana (see the Appendix for a full list of poses). The sessions started and concluded with meditation. The participants were provided a link to the yoga video, which illustrated the same poses as those practiced in the session. The participants were instructed to watch the yoga video and practice yoga twice weekly. After the final yoga session, the principal investigator re-evaluated the participants fluency skills using the SSI 4 and the OASES. The participants were instructed to read the same phonetically balanced passage, and they were presented with the same picture to elicit a speech sample. The participants completed the OASES to note any changes in their self-perception skills. The principal investigator also administered an exit survey to the participants so she could obtain their personal feedback regarding the yoga and the study. The principal investigator completed the scoring on each of the participants. In addition, all scores were reviewed with the second author of this paper. Postyoga measures were administered directly following the last session individually. One participant was tested Gatzonis & Fabus: Modified Yoga Breathing Program and Fluency 251

7 immediately following the treatment (Participant 1); the other participants (Participants 2, 3, and 4) waited between 1 to 2 hr for posttreatment measures. RESULTS We took both quantitative and qualitative measures in this study because stuttering is not only about the types and amount of dysfluencies, but it is also about the individual s perception of his or her speech. Dysfluencies analyzed in this study included hesitations, interjections, revisions, prolongations, sound repetitions, syllable repetitions, word repetitions, phrase repetitions, and blocks. Certain types of dysfluencies can be regarded as more or less typical, thus affecting their severity rating. For example, hesitations with little perceivable tension can be regarded as less severe than a block behavior with significant perceivable tension (Guitar, 2006; Van Riper, 1982). There are incidences when one dysfluent utterance consists of more than one type of stuttering behavior. For example: M m my favorite official (block) holiday? (10 syllables in conveyed message; 3 repetitions of sound, 1 block) We calculated the percentage of dysfluencies pre and post yoga treatment in order to determine if there was an effect on the participants stuttering. We found that after a modified yoga breathing program, the percentage of dysfluencies decreased in both reading and spontaneous speech tasks for all of the participants (see Table 1). The stuttering severity was calculated using the SSI 4. The SSI 4 showed a detailed analysis of each participant s stuttering based on the number of syllables stuttered, the duration of the dysfluency, and the physical concomitants (accessory behaviors) associated with dysfluent speech. Each subsection was scored and then averaged to obtain a raw score. The raw score corresponded to an overall severity rating. The fluency samples were collected pre and post yoga therapy using the same stimulus materials. The samples were transcribed including all dysfluencies and stuttering behaviors. The number of syllables stuttered was obtained and was divided by the number of fluent syllables in order to obtain a stuttering percentage. Participant 1 Participant 1 scored in the mild severity range before initiating the yoga breathing program. He scored 3.50% dysfluent in the preyoga reading task and 14.20% dysfluent in the preyoga spontaneous speech task. The average length of his dysfluencies was between 0.5 s and 0.9 s. During the preyoga reading task, the participant used hesitations; revisions; interjections; prolongations; and sound, word, and phrase repetitions. During the postyoga reading task, the participant did not have any hesitations, interjections, or revisions but continued to have sound and phrase repetitions. In the preyoga speech sample, the participant used many interjections (11 in total) and word repetitions (6) but few revisions and sound prolongations. During the postyoga speech sample, he did not use any interjections or revisions, and he decreased his use of word repetitions (2 in total). According to the SSI 4, physical concomitants refer to motor behaviors secondary to dysfluent speech such as eye blinks, jaw clenching, and hand or foot movements. Participant 1 s physical concomitants score was 7 before the yoga breathing program and 2 following the program (see Table 1). His severity rating also decreased from mild to very mild. Following the yoga breathing program, 1.36% of all of Participant 1 s syllables were dysfluent in the reading task, and 3.5% of all of his syllables were dysfluent Table 1. Stuttering Severity Instrument for Children and Adults Fourth Edition (SSI 4; Riley, 2008) scores for all participants pre and post yoga therapy. Measure Preyoga Reading % dysfluencies Spontaneous speech % dysfluencies Duration of dysfluencies (in seconds) Physical concomitants SSI 4 severity rating Mild Moderate Very severe Mild Postyoga Reading % dysfluencies Spontaneous speech % dysfluencies Duration of dysfluencies (in seconds) >0.5 > >0.5 Physical concomitants SSI 4 severity rating Very mild Very mild Mild Very mild 252 Contemporary Issues in Communication Science and Disorders Volume Fall 2015

8 in the spontaneous speech task, indicating a reduction of dysfluencies of 2.14% in the reading task and 10.67% in the spontaneous speech task. The participant also reduced the durations of the dysfluencies from s to >0.5 s. Last, the accessory behaviors associated with his stuttering dramatically decreased, going from a rating score of 7 to a rating score of 2, indicating a 5-point reduction in accessory motor behaviors. Participant 2 Participant 2 scored in the moderate severity range before initiating the yoga breathing progam. He scored 6.78% dysfluent in the preyoga reading task, and 15.40% dysfluent in the preyoga spontaneous speech task. The average length of his dysfluencies was 1.0 s. His physical concomitants score was 9 (see Table 1). During the preyoga reading task, the participant had many interjections (10 in total), revisions (4), hesitations (2), prolongations (3), sound repetitions (5) and blocks (1). During the postyoga reading task, he decreased the number of dysfluencies: interjections (4), revisions (2), prolongations (1), sound repetitions (2), and blocks (0). The participant did not have any hesitations. During the preyoga speech task, the participant had 16 interjections, seven prolongations, six sound repetitions, one word repetition, and one block. During the postyoga speech task, he had six interjections and one word repetition. Following the yoga breathing program, Participant 2 s severity rating decreased to very mild. He scored 2.44% dysfluent in the reading task and 4.27% dysfluent in the spontaneous speech task, indicating a reduction of dysfluencies of 4.34% in the reading task and 11.13% in the spontaneous speech task (see Table 1). The participant also reduced the durations of the dysfluencies from 1.0 s to >0.5 s and the accessory behaviors from a rating score of 9 to a rating score of 3, indicating a 6-point reduction in accessory motor behaviors. Participant 3 Participant 3 scored in the very severe range before initiating the yoga breathing program. She scored 5.70% dysfluent in the preyoga reading task, and 6.75% dysfluent in the preyoga spontaneous speech task. The average length of her dysfluencies was 3.0 s. Her physical concomitants score was 16, indicating pronounced physical concomitants and accessory motor behaviors (see Table 1). Following the yoga breathing program, Participant 3 s severity rating decreased to mild. She scored 0.80% dysfluent in the reading task and 7.77% dysfluent in the spontaneous speech task, indicating a reduction of dysfluencies of 4.9% in the reading task and an increase of +1.32% in the spontaneous speech task. She also significantly reduced the durations of the dysfluencies from 3.0 s to s. During the preyoga reading task, the participant had two revisions, five sound prolongations, one syllable repetition, one word repetition, one phrase repetition, and 10 blocks. During the postyoga reading task, she had two prolongations and one syllable repetition. No other dysfluencies or blocks were noted. During the preyoga speech task, the participant had one prolongation, two sound repetitions, six phrase repetitions, and three blocks. During the postyoga speech task, she decreased the number of phrase repetitions (from 6 to 1) but increased the number of interjections, prolongations, and sound repetitions. The number of blocks remained the same during postyoga testing. Participant 3 also showed a great reduction in the accessory behaviors associated with stuttering. The behaviors were reduced from a score of 16 to a score of 5, a reduction of 11 points, significantly impacting her overall severity rating from very severe to mild. Participant 4 Participant 4 scored in the mild severity range before initiating the yoga breathing program. She scored 2.71% syllables stuttered in the preyoga reading task and 11.30% in the preyoga spontaneous speech task. The average length of her dysfluencies was between s. During the preyoga reading task, she had four hesitations, one sound repetition, two word repetitions, and three blocks. During the postyoga reading task, she had one hesitation, one revision, one sound repetition, two word repetitions, and two blocks. During the preyoga speech task, the participant had seven hesitations, seven interjections, seven prolongations, one phrase repetition, and one block. During the postyoga speech task, she had six interjections and no hesitations, prolongations, phrase repetitions, or blocks. The participants physical concomitants score was 3 (see Table 1). Following the yoga breathing program, Participant 4 s severity rating decreased to very mild. She scored 1.90% syllables stuttered in the reading task, and 4.88% dysfluent in the spontaneous speech task, indicating a reduction of dysfluencies of 0.81% in the reading task and 6.42% in the spontaneous speech task. The participant also reduced the durations of the dysfluencies from s to >0.5 s and the accessory behaviors associated with stuttering, going from a rating score of 3 to a rating score of 1, indicating a reduction of two points. Gatzonis & Fabus: Modified Yoga Breathing Program and Fluency 253

9 Results of the OASES Scale We used the OASES to determine the participants self-perception regarding their stuttering. The 100- question (5-point Likert scale) test is divided into four sections: General Information, Reactions towards One s own Stuttering, Communication in Daily Situations, and Quality of Life. The questions in Section 1 refer to general information, including characteristics and experiences with stuttering and knowledge of stuttering. Section 2 addresses questions about the participant s personal reactions to his or her stuttering. It includes questions such as frequency of tension, blinks, and avoidance behaviors. Section 3 contains questions about the participant s communication in daily experiences. Within this section, the participant is asked to judge how difficult it is when speaking in various settings, such as at home, in public, at work, and in general. Section 4 contains questions about the participant s overall QOL, including information about how much stuttering affects or interferes with his or her life (i.e., not at all, a little, some, a lot, or completely). We derived calculations, or impact scores, for each section by dividing the total score of that section (A) by the total number of questions answered (B). That number was placed under a category ranging from mild to severe in terms of how much the participants stuttering impacted their lives. The test was administered pre and post yoga therapy to determine if any changes occurred. Each participant s numerical scores and responses will be discussed. Overall, the participants scored within the moderate and moderate-to-severe ranges preyoga ( ) and between the moderate-to-severe and mild-to-moderate ranges post yoga ( ) (see Table 2). Table 2 illustrates the results of the OASES for all of the participants. For example, Participant 2 scored in the moderate range (2.65) pre yoga and in the mild-to-moderate range (2.22) post yoga. According to the OASES, overall, each participant s experience remained similar (within the moderate range), with the exception of a decrease in Participant 2. Participant 1. During the preyoga assessment, Participant 1 completed the entire OASES. In Section 1, the participant indicated frequently for the general information about his speech, including how often he speaks fluently. He indicated that he is somewhat to very knowledgeable about stuttering, and somewhat negative about being an individual who stutters, being identified as someone who stutters, and having variations in his fluency. In Section 2, the participant reported his reactions to his stuttering. His reactions ranged from frequently to always in many categories. He indicated that he often feels helpless, angry, ashamed, lonely, and anxious about his stuttering and frequently avoids situations and always avoids or substitutes words. In terms of his communication in daily situations, Participant 1 reported that it was not very difficult to somewhat difficult to communicate at work, in social situations, and at home. During the postyoga assessment, he indicated similar responses as before the yoga sessions. Following the treatment sessions, Participant 1 provided feedback to the principal investigator that he felt calm and centered following the yoga practice, which allowed him to focus on his breathing. Furthermore, he stated that the connection between breathing and stuttering was insightful when striving for fluent speech. Participant 2. During the preyoga assessment, Participant 2 completed the entire OASES. In Section 1, the participant indicated frequently for the general information about his speech, including how often he speaks fluently. He indicated that he is very knowledgeable about stuttering and very negative about being an individual who stutters, being identified as someone who stutters, and having variations in his fluency. In Section 2, he reported his reactions to his stuttering. His reactions ranged from sometimes to frequently in many categories. He indicated that he often feels defensive about his stuttering and frequently avoids situations and always avoids or substitutes words. In terms of his communication in daily situations, he reported that overall, it was very difficult to communicate, somewhat difficult at work, in social situations, and at home. After receiving the modified yoga program in Section 1, Participant 2 indicated frequently for the Table 2. The Overall Experience of the Speaker s Experience of Stuttering (OASES) for all of the participants pre and post yoga therapy. Score Preyoga average Impact score Moderate to severe Moderate Moderate Moderate Postyoga average Impact score Moderate to severe Mild to moderate Moderate Moderate 254 Contemporary Issues in Communication Science and Disorders Volume Fall 2015

10 general information about his speech, including how often he speaks fluently. He indicated that he is very knowledgeable about stuttering and very negative about being an individual who stutters, being identified as someone who stutters, and having variations in his fluency. In Section 2, the participant reported his reactions to his stuttering. His reactions ranged from sometimes to frequently in many categories. He still indicated that he often feels defensive but rarely other emotions about his stuttering and now sometimes avoids situations and always avoids or substitutes words. In terms of his communication in daily situations, he reported that it was now somewhat difficult to communicate at work, in social situations, and at home. Following the treatment sessions, he reported that he found the chanting and laryngeal vibrations beneficial. He stated that he felt refreshed and positive, and he sensed an improved state of mind and increased body awareness. Participant 3. During the preyoga assessment, Participant 3 completed the entire OASES. In Section 1, she indicated sometimes to rarely for the general information about her speech, including how often she speaks fluently. She indicated that she is very knowledgeable about stuttering and somewhat negative about being an individual who stutters and having variations in her fluency. In Section 2, she reported her reactions to her stuttering. She indicated that she sometimes feels helpless, angry, ashamed, anxious, defensive, and embarrassed about her stuttering and sometimes avoids situations and sometimes avoids or substitutes words, but always experiences physical tension when speaking. In terms of her communication in daily situations, she reported that it was somewhat difficult to communicate at work, in social situations, and at home. There were no reported changes after the modified breathing program, but she did report a better understanding of the relationship between movement and breathing. She stated that breath awareness is now a goal of hers, and she is excited to continue her yoga practice. Participant 4. During the preyoga assessment, Participant 4 completed the entire OASES. In Section 1, she indicated mostly frequently for the general information about her speech, including how often she speaks fluently. She indicated that she is somewhat knowledgeable about stuttering and somewhat negative about being an individual who stutters, being identified as someone who stutters, and having variations in her fluency. In Section 2, she reported her reactions to her stuttering. Her reactions ranged from sometimes to often in many categories. She indicated that she sometimes feels helpless, angry, defensive, and embarrassed about her stuttering. She always feels anxious, embarrassed, frustrated, and ashamed about her stuttering. She indicated that she frequently does not say what she wants to say, leaves a situation because she may stutter, avoids speaking situations, and has physical tension when speaking. In terms of her communication in daily situations, she reported that it was somewhat difficult to communicate at work and in social situations, but not very difficult at home. There were no reported changes after the modified breathing program. Participant 4 did not report any changes in her feelings or perceptions following the study. DISCUSSION The aim of this study was to investigate the effects of a modified Vinyasa yoga breathing program on the fluency skills and self-perception of four adults who stutter. Both quantitative and qualitative measures were administered, including the SSI 4 and the OASES. Following the yoga breathing program, all of the participants demonstrated an improvement in their stuttering severity. These improvements included a reduction in the percentage of syllables stuttered, duration of dysfluencies, and most dramatically, accessory behaviors. There were no changes in the participants self-perception scores following the 6-week study. There is no one theory that has explained the etiology of stuttering, and no literature to date that investigates the plausibility of the Valsalva hypothesis with adults who stutter. However, the Valsalva hypothesis provides a theory about dysfluent speech based on the discoordination between the respiratory and laryngeal systems. Yoga can assist with this discoordination; therefore, yoga may be a potential treatment approach to increase fluency. It has been shown in the literature (Hoit & Lohmeier, 2000) that improvements in respiration can positively impact an individual s speech, and that yoga can contribute to improving an individual s tidal breathing and vital capacities. Yoga has also been shown to improve QOL and reduce anxiety, which is a component of stuttering (Uma et al., 1989). The participants in our study demonstrated an improvement in their stuttering severity level as a result of the modified Vinyasa yoga breathing program. Severity reductions in the SSI 4 were present in each subsection, particularly spontaneous speech and physical concomitants. The severity ratings, on average, were reduced by one to two severity ratings; one participant (Participant 3) demonstrated a reduction from very severe to mild. This substantial reduction was largely attributed to a reduction in physical concomitants following the yoga program. Gatzonis & Fabus: Modified Yoga Breathing Program and Fluency 255

11 There is no literature to date that examines the Valsalva hypothesis by using a modified breathing program; however, there is literature that discusses the benefits of yoga (Hoit & Lohmeier, 2000; Raghuraj & Telles, 2008; Ristuccia & Ristuccia, 2010; Telles & Naveen, 1997; Uebelacker et al., 2010; Uma et al., 1989). Yoga has been shown in the literature to improve an individual s respiration, reduce anxiety, and increase self-awareness. These areas of concern are frequently associated with stuttering behaviors. The positive results can be attributed to improved respiration and vital capacities, as well as an increased awareness of breath management, both of which are integral to fluent speech production. According to Shapiro (2011), very early studies of stuttering considered stuttering to be a disorder of respiration related to insufficient breath support. Perkins, Rudas, Johnson, and Bell (1976) conducted a study with 30 adults under different respiratory and phonatory conditions (i.e., voiced, whispered, and silently articulated) and found that stuttering was eliminated in 27 of the 30 participants when articulating silently. This evidence strongly supports the notion that stuttering is related to discoordination in the respiratory and phonatory mechanisms. Current theories embrace stuttering as a neurological disorder, and although these theories are important, perhaps we should reconsider respiration as a factor and take a whole-systems approach to treatment. Each individual who stutters is unique and complex; evaluation and treatment should reflect all possible etiologies in order to best address an individual s needs. Coordination between respiration and speech is a critical component to fluent speech; therefore, it is crucial that it be addressed during stuttering intervention. This study provides an innovative manner of integrating improved respiration and reduced muscular tension into traditional stuttering intervention. Stress and anxiety as a result of dysfluency can contribute to increased dysfluencies and avoidance behaviors. Stress can have numerous adverse effects on an individual, including physical, behavioral, and psychological implications (Chaoul & Cohen, 2010). In yoga-related research, the most consistent result has been stress reduction (Douglass, 2011). In this study, all of the participants reported feelings of relaxation and reduced anxiety in a postyoga exit survey, and this was evident in each participant s physical concomitants rating following the final assessment. The aim of stuttering intervention is to either increase fluency and/or facilitate ease of stuttering to improve communication, and to decrease physical tension associated with stuttering. The implications of reducing physical tension during speech can be meaningful from the clinical standpoint because it is directly related to the perceived severity of stuttering by the speaker and observers and to communication (Martin & Haroldson, 1992; Riley, 1972). By reducing the perceived severity of stuttering from a speaker s standpoint, we may also be able to eventually improve an individual s self-perception as severity is directly correlated with self-perception. In a study by Snidecor (1955; as cited in Tichenor & Yaruss, 2013), the investigators found that the most commonly reported areas of the body where tension was present were the jaw, front of the tongue, front of the throat, inside or back of the throat, chest, and abdomen. The yoga postures selected for our study were tailored to target these areas of the musculature and to improve respiratory function in coordination with speech production. Speech and yoga both combine a series of complex motor movements coordinated with respiration. Each yoga pose had a corresponding breath during execution. The quantitative results of the OASES scales indicated that the participants in the study did not perceive any changes in their self-perception; however, three of the four participants indicated an increased awareness of their respiration and speech systems. The lack of quantitative evidence could be attributed to several factors. First and foremost, the length of the study was 6 weeks. Attitudes about stuttering, which have evolved over an adult s lifetime of dysfluencies, may not be significantly changed in such a short period of time. Our participants were adults, and it is likely that changing deep-rooted attitudes and feelings about dysfluency requires a lengthier process. We found that the participants attitudes remained similar before and after the yoga program, scoring within the moderate range. This stability in scores may be a result of a short treatment protocol. Negative attitudes and poor self-perception can take years to modify. Yoga is regarded as a lifelong practice that can take years to truly have an effect on an individual s attitudes and self-perception. Additionally, it was noted that only one participant (Participant 1) reported completing the required home practice video twice during the study. This was confirmed via checking each participant s unique video link, which indicated the number of times the participant watched the video. Clinical Implications Yoga is an affordable, easy-to-perform treatment that does not require significant financial investment or equipment or lengthy training to begin practicing; it can be incorporated into a clinical treatment program with ease. According to Bennett (2006), learning 256 Contemporary Issues in Communication Science and Disorders Volume Fall 2015