Biofeedback and Self-Regulation, Vol. 4, No. 4, 1979

Notes and Comments

Some Comments on "Biofeedback in the Treatment of Psychophysiologic Disorders: Stuttering" Jeffrey M. Stromer Queensborough Community College, The City University of New York

Two issues raised by Fotopoulos and Sunderland (1978) relevant to biofeedback therapy for stuttering are dealt with. Their concerns about the optimal site for relaxation and mode of feedback must be answered by observations of individual clients. Two issues raised by Fotopoulos and Sunderland (1978) merit further discussion. The first concerns choice of electrode site. There is no reason to assume that there is a single most effective site for electrode placement in biofeedback-stuttering therapy, as Fotopoulos and Sunderland seem to call for. Clinical experience with stutterers reveals that their stuttering and secondary behaviors show great intersubject locus variability. They exhibit high tension levels in masseter, obicularis oris, mentalis, suprahyoids, and internal laryngeal muscles, among them cricothyroid, posterior cricoarytenoid, and interarytenoid. The eye and facial muscles are often sites of secondary symptomatology. If there is any commonality among stutterers, it is that most exhibit airway disruptions ranging in locus from the laryngeal glottis up to the lips. The most common site for airway disturbances appears to be at the glottis, where Freeman and Ushijima (1978) noted abnormally high general levels of laryngeal muscle activity and disrupted coordination of adductorabductor muscles. Since normal speech phonation requires a high level of adductor-abductor synchrony and reciprocity, as well as rapid and continuous adjustment, high muscle tension levels at the laryngeal site can potentially inhibit the phonatory process. Van Riper (1971) and Schwartz (1974), as well as the present author (Stromer, 1977), feel that stuttering is often accompanied by a laryngeal muscle spasm; Guitar (1975) reflects that the spasm not only accompanies 383 0363-3586/79/1200-0383503.00/0 © 1979 Plenum Publishing Corporation

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Stromer

the stuttering block but may precipitate it. Mysak (1966) and Bloodstein (1969) see laryngeal spasms as being part of the stutterer's "preparatory set," a defensive clenching maneuver adopted as a reaction to anticipated speech breakdown. This maneuver, in turn, may be a primary cause of the breakdown. The fact remains, however, that some stutterers adopt preparatory sets in other muscles as well. The remaining choices for relaxation site specification would then involve (1) choosing the site showing the highest EMG level during blocks, a very tedious process, or (2) dependence upon the clinician's experience and judgment. The latter involves intuitions based upon either voice quality breakdowns or airflow deviations during observed blocks, or an analysis of those sounds that seem to be most often or most strenuously blocked. For example, some stutterers display a high degree of visible obicularis oris tension during the production of b i l a b i a l / m / , / b / , or / p / s o u n d s . The lips will clearly lock or exhibit tremors. In any event, the positive effects of EMG biofeedback training are usually exhibited fairly quickly (during the first few sessions), so an error in choice of electrode placement need not be very time-costly. A shift to a new site and relaxation of that site can probably be achieved quickly. A second issue raised by Fotopoulos and Sunderland is that of feedback modality. In our own work (Stromer, 1977) and that of others (Guitar, 1975; Hanna, Wilfling, & McNeill, 1975) the auditory modality was used effectively without disrupting attempts at fluent speech production. The client accepts and understands the significance of low frequency output from the instrumentation. We would suggest using a loudspeaker rather than earphones, since the sound can be monitored just as well but is relegated aurally and tactually to the background. We can understand why the presence of a sound source on the ear might serve to distract the stutterer from his spoken message form and content. It is clinically useful for the clinician to be able to hear the signal as well. Our own subject (Stromer, 1977) could benefit from either the visual or the auditory mode but preferred the auditory at times. Again, stutterers are variable; some may prefer one mode against the other. The fact that concentration in the visual mode may affect brain-wave frequency should also be considered. The dictum "What works best is what is best" should apply. Anything that will maintain learning and motivation at a maximal level should be utilized. We must concur with Fotopoulos and Sunderland in their appraisal of the role of the clinician. Biofeedback work implies a close harmony among the client, the clinician, and the instrumentation. While support and praise should be carefully monitored and controlled in the experimental situation, they are essential to many types of stuttering therapy and are the binding element in EMG biofeedback-stuttering work.

Some Comments on Biofeedback

385 REFERENCES

Bloodstein, O. A handbook on stuttering. Chicago: National Easter Seal Society, 1969. P. 34. Fotopoulos, S. S., & Sunderland, W. P. Biofeedback in the treatment of psychophysiologic disorders: Stuttering. Biofeedback and Self-Regulation, 1978, 3, 339. Freeman, F. J., & Ushijima, T. Laryngeal muscle activity during stuttering. Journal of Speech and Hearing Research, 1978, 21, 538-562. Guitar, B. Reduction of stuttering frequency using analog electromyographic feedback. Journal of Speech and Hearing Research, 1975, 18, 672-685. Hanna, R., Wilfling, F., & McNeill, B. A biofeedback treatment for stuttering. Journal of Speech and Hearing Disorders, 1975, 40, 270-273. Mysak, E. D. Speech pathology and feedback theory. Springfield, Illinois: Charles C Thomas, 1966. P. 21. Schwartz, M. F. The core of the stuttering block. Journal of Speech and Hearing Disorders, 1974, 39, 169-177. Stromer, J. M. Laryngeal stuttering and biofeedback therapy. Paper presented at the annual spring conference of the Long Island Speech and Hearing Association, Hofstra University, New York, 1977. Van Riper, C. The nature of stuttering. Englewood Cliffs, New Jersey: Prentice-Hall, 1971. (Revision received June 20, 1979)