Could Voice Therapy be a Remedy for Stuttering?

black and white wavy lines/pattern

Photo by edwin_young

It has been long known that stuttering, especially in severe cases with blocks, stops and interjections, could produce a real voice disorder as a post effect.

In most of these cases of severe stuttering, while the patient is blocking his speech we can see how much pressure is building below the closed vocal cords until they finally open for that interjection of speech production, causing the upper circulatory neck veins to be full of blood,well shown and causing a severe friction effect on the vocal cords themselves.

Thus, there is not much surprise in the clinical connection between stuttering and a secondary voice disorders. The voice of these stutterers is harsh, choppy, and very distinct.

Voice therapy might help with stuttering – really?

Speech pathologists who treated many stutterers throughout the years have seen numerous times that by treating the secondary voice disorder not only is voice quality improved but, surprisingly enough, the stuttering has become less severe and in some cases is gone completely!

This is actually not so surprising…any speech pathologist who has the specialty to treat stuttering will tell you that one of the best remedies clinically proven is to change the output pattern of the patient speech. Since voice therapy is doing just that…it may as well be a wonderful remedy for severe stuttering.

What would be the clinical procedure?

In the evaluation process I see many stutterers with a secondary voice disorde. While testing the voice and speech production of these patients I will decide which of the disorders to tackle first and which technique to use. Most probably if the patient’s voice is harsh and choppy I will choose to treat him with a technique that will try to solve both disorders or, rather, to do voice therapy that will decrease the vocal abuse secondary to his fluency disorder and improve his vocal production while working against his dis fluency behaviors by changing the speech production process all together.

What exactly do we do in voice therapy against stuttering?

There are typically a couple of very good techniques to choose from nowadays. While any voice therapy technique that will work to change the breath support pattern of the patient while advocating vocal cords relaxation physiotherapy is good and will have positive results on both the stuttering disorder as well as on the secondary voice hoarseness, I would much prefer to use state-of-the-art techniques that are more suitable for this complex combined situation of an Hoarse-Stutterer.

Let me briefly discuss 2 specially designed techniques for that:

WMD (Sonorantic) technique:

Introduced by Watterson,McFarlen and Diamond , features use of sonorants ( nasal consonants like /M/ and /N/ and liquids (half a vowel) like /Y/) in the teaching materials while implementing a change to abdominal breath support and emphasizing relaxation drills to the vocal cords. The idea behind this unique technique is that when we produce these sonorants , friction in the vocal cords is much reduced compare to using materials with ordinary common consonants – making this a best match to these stutterers!

MMSM (Minimal Movements Specialization Method) technique:

Introduced by Dr. Weiss, was designed as a voice coaching technique for singers and actors , then was implemented as medical voice therapy and has shown tremendous success with these actors that had dis fluency problems prior to treatment. Again, we see the power of changing the speech pattern in these patients. This relatively new fascinating technique may become a powerful weapon against stuttering since it features not one good voice but a thousand of good voices…the patient is learning how to control his vocal output using minimal movements of his speech muscles, making it possible to change the voice output in thousand different ways, so you could have a different speech pattern every day…which will most probably will have a vast positive effect on any stutterer’s speech outcome, and by decreasing the primary disorder will reduce voice abuse to solve the secondary voice disorder as well.

Gal Levy M.Sc. CCC-SLP, has more than 21 years of experience in clinical treatments of Voice, Fluency, Articulation and Language. Gal is working as a school based SLP, Home health SLP and in his private practice at Frisco, TX. He also writes professional articles on various speech disorders and state of the art treatments on Google’s new Encyclopedia, Helium and AC writers websites. Gal participated on Community Focus radio monthly shows with Dr. Griffin advising KEOM 88.5 FM listeners on voice, fluency and tongue thrust clinical issues.

Tongue Thrust and Treatment of Subsequent Articulation Disorders

What is tongue thrust?

Tongue thrust (also called “reverse” or “immature” swallow) is the common name given to orofacial muscular imbalance, a human behavioral pattern in which the tongue protrudes through the anterior incisors during swallowing, speech and while the tongue is at rest. Nearly all young children exhibit a swallowing pattern involving tongue protrusion, but by the age of 6 most have automatically switched to a normal swallowing pattern. (Wikipedia).

Why is it a concern?

Dentists and orthodontists are concerned with the effects of the tongue and facial muscles on the occlusion (how teeth fit together) of teeth because of the evidence proving that too much tongue pressure against the teeth on the inside and an unequal amount of facial muscle pressure from the outside – as is the case with a tongue thrust swallow and/or incorrect tongue resting posture – may result in a malocclusion or misalignment of the teeth – the resting posture of the tongue and facial muscles play an even more vital role: If the tongue is constantly resting against the front teeth and the upper lip in short or flaccid (weak and flabby), the front teeth will be pushed forward.

Thus, correcting this tongue thrust using special speech techniques will play a crucial role in any good orthodontic treatment, making the treatment’s results long lasting and much easier to achieve.

What are some signs of having a tongue thrust problem?

One or more of the following conditions may clearly indicate tongue thrust disorder and should be investigated further with an evaluation of speech pathologist:

  1. Tongue protruding between or against the upper and/or lower “front teeth” when forming /s/, /z/, /t/, /d/, /n/, /l/, or /sh/
  2. Frequent open-mouth resting posture with the lips parted and/or the tongue resting against the upper and/or lower teeth
  3. Lips that is often cracked, chapped, and sore from frequent licking
  4. Frequent mouth breathing in the absence of allergies or nasal congestion

Treatment of tongue thrust and subsequent articulation disorders

To correct tongue thrust, speech pathologists prescribe exercises designed to promote a normal swallowing pattern, as well as correct speech production. In the evaluation session the patient will be given swallowing and articulation inventory tests. If only “pure” tongue thrust is found without any articulation errors then usually three sessions are enough.

At this evaluation session the patient will be given the main set of drills against tongue thrust that he has to do on a daily basis for 60 days following this session. A second session will be scheduled 4 weeks later to follow up on the results of this oral physiotherapy and consider adding another set of drills for the next 4 weeks after which the third session is scheduled with follow up on the results.

If the patient has misarticulated consonants (usually the high pitched ones: /s/ , /z/ , /sh/ , /ch/ , /ts/) – then each sound will have to be corrected in a 8-session weekly speech therapy while doing the same oral physiotherapy for 60 days – as well as specially designated speech drills to correct each sound…The good news are that by successful correction of one sound we may correct another (for example: correcting the /s/ may solve the problem with the /ts/ sound).

Gal Levy M.Sc. CCC-SLP, has more than 21 years of experience in clinical treatments of Voice, Fluency, Articulation and Language. Gal is working as a school based SLP, Home health SLP and in his private practice at Frisco, TX. He also writes professional articles on various speech disorders and state of the art treatments on Google’s new Encyclopedia, Helium and AC writers websites. Gal participated on Community Focus radio monthly shows with Dr. Griffin advising KEOM 88.5 FM listeners on voice, fluency and tongue thrust clinical issues.

Stuttering Versus Cluttering – What’s the Difference?

"speech bubble" balloons


Photo by milgrammer

What is stuttering?

Stuttering is a disruption in the fluency of verbal expression characterized by involuntary, audible or silent, repetitions or prolongations of sounds or syllables. These are not readily controllable and may be accompanied by other movements and by emotions of negative nature such as fear, embarrassment, or irritation (Wingate 1964). Strictly speaking, stuttering is a symptom, not a disease, but the term stuttering usually refers to both the disorder and symptom. The stutterer is doing the opposite of what normal speaker would do: He is trying to talk on inhalation instead of after inhalation. He does this as a reaction to the fact that most of his air being exhaled BEFORE it can be used for phonation.

What is cluttering?

Cluttering is a disorder of both speech and language processing that frequently results in rapid, dysrhythmic, sporadic, unorganized, and often unintelligible speech (Daly, 1993).

How can we differentiate between stuttering and cluttering?

The clutterer vs. stutterer:

  • Talks BETTER under stress
  • Talks BETTER when interrupted
  • Talks BETTER on longer sentences
  • Talks BETTER in a foreign language
  • Reads BETTER unfamiliar texts
  • Doesn’t seem to care how he talks
  • Doesn’t have remissions in his speech disorder
  • Talks WORSE when calm
  • Doesn’t pay attention to what is said
  • Unaware of his speech

Can they co-exist? YES!

A patient may show symptoms of BOTH disorders together. Thus, he will be classified as clutterer-stutterer and will show: word-finding difficulty, poor reading abilities, poor memory, poor story-telling abilities and interestingly, superior skills in math and science (Daly, 1993).

How do we treat stuttering and cluttering?

Treatment for stuttering disorder is not easy – since we don’t really know the cause for sure, we try to manipulate the speech production using: mind control/attitudes, changing the speech patterns (clinically proven to help a lot of patients!), changing breathing patterns  (most beneficial to those patients that acquire hoarse voice due to their stuttering!), and teaching muscles relaxation.

Treatment for cluttering might be even harder and differs from treatment of stuttering. We typically will be working on awareness of the patient towards his speech problem , teaching oral-motor coordination exercises  (to stop the mumbling effect), teaching relaxation drills, emphasizing organizational language treatment, teaching memory strategies, teaching rate control techniques (clinically proven to help a lot of patients!).

Gal Levy M.Sc. CCC-SLP, has more than 21 years of experience in clinical treatments of Voice, Fluency, Articulation and Language. Gal is working as a school based SLP, Home health SLP and in his private practice at Frisco, TX. He also writes professional articles on various speech disorders and state of the art treatments on Google’s new Encyclopedia, Helium and AC writers websites. Gal participated on Community Focus radio monthly shows with Dr. Griffin advising KEOM 88.5 FM listeners on voice, fluency and tongue thrust clinical issues.

Spasmodic Dysphonia or “Stuttering of the Vocal Cords”

What is Spasmodic Dysphonia?

Laryngeal Dystonia–also called Spasmodic Dysphonia– is an organic voice disorder caused by dysfunction of center neurological integration that produces spasm of the vocal cords. Spasmodic dysphonia causes the voice to break or to have a tight, strained or strangled quality. There are three different types of spasmodic dysphonia: adductor spasmodic dysphonia (closed glottis), abductor spasmodic dysphonia (open glottis) and mixed spasmodic dysphonia.

In adductor spasmodic dysphonia, sudden involuntary muscle movements or spasms cause the vocal cords to slam together and stiffen, which makes it difficult for the them to vibrate and produce voice. Words are often cut off or difficult to start and speech may be choppy and sound similar to stuttering. The voice is commonly described as strained or strangled and full of effort.

In abductor spasmodic dysphonia, the sudden involuntary muscle movements or spasms cause the vocal folds to open and stay opened. Thus, vocal cords can not be closed for phonation (to produce the speech sounds). As a result, the voice of these individuals often sounds weak, quiet and breathy or whispery.

Mixed spasmodic dysphonia involves muscles that open the vocal folds as well as muscles that close the vocal folds and therefore has mixed features of both above–mentioned syndromes.

Surprisingly, all three conditions are usually absent while doing vegetative phonation, whispering, crying, laughing, singing, speaking at a high pitch, speaking when just woken up from a sound sleep or after drinking alcoholic beverages ( spasmodic dysphonia is the only voice disorder for which I am allowing my patients to drink some alcohol!) As in many other voice disorders, stress and nervousness will make the muscle spasms even more severe.

Spasmodic dysphonia is a mysterious voice disorder; the cause is yet unknown. Because the voice can sound normal at times, spasmodic dysphonia was once thought to be psychogenic, but as reported by the National Institute of Deafness and other Communication Disorders (NIDCD), research has revealed increasing evidence that most cases of spasmodic dysphonia are in fact neurogenic and may co-occur with other movement disorders such as blepharospasm (excessive eye blinking and involuntary forced eye closure), tardive dyskinesia (involuntary and repetitious movement of muscles of the face, body, arms and legs), oromandibular dystonia (involuntary movements of the jaw muscles, lips and tongue), torticollis (involuntary movements of the neck muscles), or tremor (rhythmic, quivering muscle movements).

NIDCD also reports that spasmodic dysphonia may run in families and is thought to be inherited. Research has identified a possible gene on chromosome 9 that may contribute to the spasmodic dysphonia that is common to certain families. Spasmodic dysphonia can affect anyone between 30 and 50 years of age. More women appear to be affected by spasmodic dysphonia than are men.

Treatment for spasmodic dysphonia?

The “triangle” ENT–Neurologist–SLP is usually on the front line in diagnosing and treating the symptoms of spasmodic dysphonia. There is presently no known cure for spasmodic dysphonia. Current treatments only help reduce the symptoms.

SLP- Voice therapy may reduce some symptoms, especially in mild cases. Voice therapy and vocal cords special physiotherapy may also support a better voice while undergoing the post effects of treatment of choice – see below.

ENT- has two common options:

  1. an operation that cuts one of the nerves of the vocal folds (the recurrent laryngeal nerve) thus improving the voice for several months to several years.
  2. injections of very small amounts of botulinum toxin (botox) directly into the affected muscles of the larynx. Botulinum toxin is produced by the Clostridium botulinum bacteria. The toxin weakens muscles by blocking the nerve impulse to the muscle. Botox injections generally improve the voice for a period of three to four months after which the voice symptoms gradually return. Reinjections are necessary to maintain a good speaking voice. Initial side effects that usually subside after a few days to a few weeks may include a temporary weak, breathy voice or occasional swallowing difficulties – this will be the best time to refer the patient to speech therapy , as was mentioned above. Botox may relieve the symptoms of both adductor and abductor spasmodic dysphonia, and is considered to be the main line of defense against spasmodic dysphonia.

Gal Levy M.Sc. CCC-SLP, has more than 21 years of experience in clinical treatments of Voice, Fluency, Articulation and Language. Gal is working as a school based SLP, Home health SLP and in his private practice at Frisco, TX. He also writes professional articles on various speech disorders and state of the art treatments on Google’s new Encyclopedia, Helium and AC writers websites. Gal participated on Community Focus radio monthly shows with Dr. Griffin advising KEOM 88.5 FM listeners on voice, fluency and tongue thrust clinical issues.