L a r y n g e a l Behaviour and Fluency-inducing Therapy 

Marlene Behrmann MA (Speech Path.) (Witwatersrand) 
Department  of  Speech Pathology  and  Audiology, 

University  of  the  Witwatersrand,  Johannesburg 

Itemed  behaviour of  an adult  stutterer  was assessed  pre- and  post-therapy  intervention.  I n t e r v e n t i o n  comprised  a fluency  based 
ram^directedto  the modification  ofphonatory  behaviour and  rate reduction.  Electrolaryngographic  tracings,  as well  as seventy and 

T ^ L  ratZs  Vere  obtained  pre- ail post-intervention.  Results  revealed  a marked  change in all  measurements post-intervention,  m-
^cating  the effectiveness  of  therapy. The  'efficacy  of  the electrolaryngograph  as a measurement tool  was illustrated  and  the results  are 
considered  in the light  of  the current  literature  on phonatory disturbance  in stuttering. 

TelTZfegedrag  van >n volwasse hakkelaar  is pre- en post-terapeutiese  ingryping  ondersoek.  Ingryping  het uit'n  vlotheidsgebaseerde 
^roe^am  ger'g  °p d'e  ^ S m  van fonatoriese  gedrag  en vermindering  van spoed,  bestaan. Eiektrolaringeografiese  op ekeninge  asook 
Zoliin  o '  die  graad  en.frelensie  van die  hakkelgedrag,  is voor en na terapeutiese  ingryping  verkry.  Die doeltreffendheid  van 
terapfe  isbewys deurdat  η opvallende  verskil  t.o.v. alle  post-ingrypingsmetings  gemerk  is. Die effektiwiteit  van die  elektrol^og  aaf 
as meetinstnment  is aangetoon  en die  resultate  is teen die  agtergrond  van die  huidige  literatuur  i. v. m. fonatoriese  asking  in hakkel  bespreek. 

program is to establish rate control and this dimension together with 
the emphasis on phonatory adjustments, has currently proved to 
be the most effective  variable handled in treatment (Andrews et 
al. 1982). The Stutter Free therapy program falls  within the 'Speak 
More Fluently' school of  stuttering therapy, as discussed by Gregory 
(1979). These approaches, also known as the fluency-inducing  ther-
apies, advocate the establishment, maintenance and transfer  of  an 
entirely new speech pattern. The call for  clearer delineation and 
identification  of  the factors  which contribute to the success or failure 
of  stuttering therapy has been made by Boberg, Howie and Woods 
(1979) and continued research into the outcome of  therapy is neces-
sary both to predict the amount of  change and to enhance and modify 
existing treatment regimes. 

The concept of  an organic etiology of  stuttering is not a novel one, 
stuttering having been ascribed to, among others, neurological 
causes, auditory perception problems and biochemical factors  (Van 
Riper 1978). Recently, numerous allusions to abnormal laryngeal 
functioning  of  stutterers have been made, but whether this abnor-
mal functioning  is due to etiological or symptomatological factors 
is as yet undetermined and may indeed prove unanswerable. 
Several writers have stated that the problem resides in the larynx 
itself  whilst others have suggested that an overriding neural com-
ponent is responsible for  the disturbed phonatory behaviour (Con-
ture, McCall and Brewer 1977). The stutterer's inability to initiate 
phonation and to make vocalization adjustments has been examined 
(Adams and Reis 1971), as hasjvoice onset time problems (Cross 
and Luper 1979) and unusuajl abductory laryngeal behaviour 
(Schwartz 1974). Perkins (1981) has concluded that there exists 
a "mistiming and excessive contraction of  laryngeal and supraglottal 
muscles". 

One of  the difficulties  in examining the laryngeal behaviour of  stut-
terers arises from  the lack of  testing equipment. The development 
of  the electrolaryngograph affords  the researcher the opportunity 
of  investigating the phonatory pattern of  a speaker in a non-invasive 
manner (Fourcin and Abberton 1971). This technique which pro-
vides a dynamic, instantaneous and simple method for  assessing 
vocal fold  contact and for  examining the laryngeal behaviour of 
stutterers, has not been extensively applied to stuttering nor has 
it been used to evaluate the laryngeal behaviour pre- and post-
intervention. The laryngographic tracings are obtained by placing 
two electrodes on either side of  the thyroid cartilage. The output 
is derived from  the voltage variations which result in the changing 
conductance of  the vocal fold  configurations. 

A potential application of  the electrolaryngograph is as a means 
of  examining laryngeal functioning  following  therapy which has 
been instituted specifically  to modify  vocal fold  movement. One 
such therapy program, "Stutter Free Speech" (Shames and Flor-
ance 1980) is designed to modify  the phonatory behaviour of  the 
speaker through continuous phonation. A further  purpose of  this 

Die Suid-Afrikaanse  Tydskrif  vir Kommunikasieafwykings,  Vol.  32, 1985 

METHODOLOGY 

The aim of  the current study is to evaluate the change in a stut-
terer's laryngeal behaviour following  a therapy program designed 
to intervene at the level of  phonation. The applicability of  the elec-
trolaryngograph as a measurement tool of  laryngeal behaviour will 
also be considered. 

A single case study design was selected in accordance with Per-
kins (1983) proposal that studies "with an Ν of  1" support the ten-
dency away from  hypothetical speculation and provide much needed 
empirical evidence. 

SUBJECT DESCRIPTION 

The subject, S, was a 31 year old male who had stuttered since 
early childhood. No family  history of  stuttering had been report-
ed. S had received therapy previously but there had been no ob-
servable change in his speech pattern. No previous history of 
laryngeal pathology had been noted. S presented as aPhase lV ad-
vanced stutterer, According to Luper and M u l d e r s ( 1964) classifi-
cation system. His speech pattern was charactered by severe blocks 
and hard contacts, tense repetitions and interjections of  phonemic 
a i d non-phonemic utterances. Tension loci were identified  as the 
Hps, tongue, laryngeal area and abdomen. Secondary behavtours 

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46 Marlene Behrmann 

included eye blinking, head jerks, lip tremor and flaring  of  the nos-
trils. Respiratory disturbances were evident in frequent  pausing, 
gasping and speaking on residual air. Fluency facilitating  techniques 
(utilised prior to the implementation of  a therapy program) such 
as whispering, choral speaking and slowed speech produced a 
decrease in the frequency  and severity of  stuttering. S obtained a 
score of  12.9 on the Erikson S24 (1969) scale which suggests that 
he viewed himself  in a positive light prior to intervention. 

PRE-INTERVENTION SPEECH ASSESSMENT 

The need for  comprehensive assessment pre-intervention has been 
highlighted by Andrews, Guitar and Howie (1981). A pre-
intervention percentage of  syllables stuttered (%SS) and a mean 
syllable per minute (SPM) were computed in order to describe the 
frequency  and severity of  the stutter pattern. A sample of  S's speech 
was collected including a spontaneous speech sample, a reading 
sample and a telephone call interchange. These varying conditions 
were included since Bloodstein (1975) contended that the stutter 
pattern varies under different  circumstances. For the purposes of 

, this study, stuttering was defined  as "any sound or syllable repeti-
tion, block, prolongation or effortful  emission of  a word or syl-
lable" (Ingham, Andrews and Winkler 1972). 

The pre-intervention %SS were 26,5%, 18,2% and31,4% for  the 
three samples outlined above. These figures  are suggestive of  a se-
vere stutter pattern in comparison with previous studies (Goldsmith 
and Anderson 1984) and support the classification  of  S as a Phase 
IV advanced stutterer. The mean SPM counts were 139,5, 132 and 
123 for  the three samples and are all slow compared with the norm 
of  196 SPM for  normal speaking adult males (Andrews and Ingham 
1971), thus confirming  the diagnosis of  a severe stutter pattern. 

The electrolaryngographic examination was conducted using a Uher 
4200 report Stereo I.C. Tape Recorder with a M816 directional 
microphone to record the subject's spoken output while the Min-
gograf  inkjet recorder traced the laryngeal information.  The sub-
ject was seated in a comfortable  position with the microphone at 
a distance of  30mm from  the lips. Tracings were made on both a 
spontaneous speech sample and a reading sample. Owing to prac-
tical difficulties  the tracings could not be carried out during a tele-
phone conversation. The dimensions for  analysing the 
laryngographic tracings were selected to yield a comprehensive pic-
ture of  laryngeal functioning.  Examples of  the pre-intervention trac-
ings are presented in Figures la and lb which reflect  the spontaneous 
speech and reading samples respectively. 

a. Regularity  of  the wave - this dimension refers  to the maintenance 
of  a stable vibratory pattern which is achieved through the laryn-
geal musculature and through air pressure control. Much variabil-

^ ^ ^ ^ — r ^ m i m ^ ^ 
- v w s / w v w · — 

ivvv-</vvuwnnfl/i/|l» 

VUUUUIA^^ 

immrnwrnMNmh 

/V»/ 

Figure la Examples of  pre-intervention spontaneous speech 
laryngographic tracings 

Figure lb Examples of  pre-intervention laryngographic tracings 
during reading 

ity and erratic movement may be observed in Figures la and lb 
and these tracings reflect  a disturbance in laryngeal functioning  and 
co-ordination as described by Conture et al. (1977). An alternative 
explanation is that the laryngeal inco-ordination results from  an un-
even interplay between the agonist and non-agonist laryngeal mus-
cles. These results are supported by studies which have demonstrated 
abnormal laryngeal functioning  in stutterers (Adams and Reis 1971; 
Schwartz 1974). 

b. Shape  - the shape of  the waveform  (Lx) provides a basis for 
determining the nature of  the vocal fold  contact and its timing (An-
thony 1978). A normal vibratory cycle consists of  a rapid closing 
phase (adduction), represented by a vertical rise, a slower opening 
phase (abduction) shown as a downward tracing and a period of 
no contact when the glottis is opening. The pre-intervention spon-
taneous speech tracing (Fig. la) reflects  an erratic pattern of  vocal 
fold  movement as noted in the poorly proportioned rise and fall 
times and the exaggerated gradual decline owing to the failure  of 
the folds  to meet along their entire length. The double peak at base 
provides further  evidence for  asynchronous vibration. 

c. Ease of  achieving steady  amplitude  — this dimension, measured 
from  the first  excitation until steady amplitude is achieved, reflects 
the ease with which a stable vibratory pattern is instituted. An im-
pressionistic overview reveals that steady amplitude is achieved rela-
tively quickly in the pre-intervention tracings, although amplitude 
variations are noted on the fluent  and stuttered phonatory stretches. 
This pattern is indicative of  a difficulty  in regulating the vibratory 
pattern even during the fluent  phases of  speech. 

d. Fx:  refers  to the fundamental  frequency  of  voicing (Anthony 
1978) and the term 'jitter' has been coined to describe the Fx pitch 
variations. The relative degrees of  rise and fall  provide crucial in-
formation  about normal and deviant vibration patterns. Sporadic 
jitter, especially at the onset of  phonation, was evident across all 
conditions. Almost the entire pre-intervention utterance was charac-
terized by jitter, suggestive of  an uneven mode of  vocal fold  vibra-
tion. The increases in Fx reflect  the tension of  the laryngeal muscles 
and increased subglottic air pressure. 

e. Gx: refers  to the observation of  gross laryngeal adjustments. This 
dimension is superimposed on the Lx waveform.  Rapid laryngeal 
adjustments are noted pre-intervention especially on the spontane-
ous speech sample. This finding,  however, must be viewed with 
caution since the excess Gx activity may have resulted from  the 
subject's secondary symptoms such as head jerks (although the sub-
ject was requested to remain still during the recordings) and not 
necessarily from  laryngeal activity. In view of  this, any judgements 
on pre-intervention Gx must be reserved. 

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Laryngeal Behaviour and Fluency-inducing Therapy 47 

In sum, the pre-intervention laryngographic tracings reflect  disturbed 
phonatory patterns as evidenced by, for  example, the variable wave-
form,  amplitude variations and irregular shape. These findings  sug-
gest a dysfunction  at the laryngeal level both during spontaneous 
speech and during reading. The laryngeal abnormalities noted on 
the reading tracings are not as marked as those on the spontaneous 
speech tracings. 

THERAPY PROCESS 

An intensive schedule of  therapy was undertaken since the subject 
lived out of  town and a limited time period was available. In many 
instances intensive therapy has been regarded as the ideal form, 
especially in a fluency  based program as the 'new' speech pattern 
may be acquired in a short period of  time. Twenty three hours of 
therapy were completed in ten days. The first  three stages of  the 
Stutter Free program were completed. This involved the establish-
ment of  a fluent  speech pattern under volitional control as well as 
self-reinforcement  and transfer.  It was hoped that an alternative form 
of  laryngeal behaviour would be achieved by this stage and that 
the remaining two phases of  the program (unmonitored speech and 
follow-up)  would be monitored over a long period of  time. 

A number of  modifications  were made to the program, devised by 
Shames and Florance (1980). Delayed auditory feedback  was ex-
cluded since the subject achieved continuous phonation of  his own 
accord. Syllables per minute were calculated instead of  words per 
minute as words differ  in their syllable count and do not facilitate 
cross-language comparison (Hayhow 1983). Pre-planned contract 
activities were arranged in a hierarchical manner in accordance with 
Van Riper's (1978) suggestions. 

Post-intervention measurements were taken following  the termi-
nation of  the therapy and compared to the pre-intervention baselines. 

POST-INTERVENTION SPEECH ASSESSMENT 

The post-intervention tracings were taken following  the identical 
procedure of  the pre-intervention recording. Figures 2a and 2b 
depict examples of  the post-intervention tracings. 

/ h e i p i ^ t t e V ^ · * 

Figure 2a Example of  post-intervention spontaneous speech 
laryngographic tracing 

a. Regularity  of  the wave — the post-intervention tracings reflect 
a moreregular and stable waveform  post-intervention than the pre-
intervention tracings. Figures 2a and 2b suggest a controlled vibra-
tory pattern of  the vocal folds. 

b. Shape  — a synchronous, symmetrical mode of  vibration is evi-
dent from  the spontaneous speech and reading post-intervention trac-

Die Suid-Afrikaanse  Tydskrif  vir Kommunikasieafwykings,  Vol.  32, 1985 

mmmmmwmmummm^M 

Figure 2b Example of  post-intervention laryngographic tracing 
during reading 

ings. A distinguishing feature  of  these tracings is the relatively flat 
base which suggests a long open phase of  the vocal folds.  Figures 
2a and 2b resemble each other closely although the spontaneous 
speech tracing (Figure 2a) contains more evidence of  abnormality 
than the reading tracing. The reading tracing (Figure 2b) demon-
strates a sharp vertical rise (closure) associated with maximum ex-
citation of  the folds  followed  by a sharp peak or short period of 
maximum contact. The decline is vertical and the rise and fall  times 
are well proportioned. These results approximate normal laryngeal 
functioning. 

c. Ease of  achieving steady  amplitude  - a change in amplitude 
control following  intervention is observed since no amplitude var-
iations are noted on the post-intervention tracings. The absolute am-
plitude cycle could not be compared across the pre- and 
post-intervention tracings since the gain on the laryngograph was 
turned up on the post-intervention recording and hence any differ-
ences may be a result of  artifact. 

d. Fx:  the post-intervention tracings depict a stable Fx and thus 
suggest the elimination of  the tension of  the laryngeal muscles. 

e. Gx: Post-intervention tracings reveal no Gx activity thus provid-
ing further  evidence for  a change in laryngeal behaviour. Table 1 
summarises the overall trends of  the laryngographic tracings and 
allows for  comparisons across the pre- and post-intervention con-
ditions. 

Table 1 Summary of  overall trends of  laryngographic 
analysis pre- and post-intervention 

Pre-intervention 
Speech Reading 

Post-intervention 
Speech Reading 

a. regularity of  Lx wave + - + - + + 

b. normal vibratory cycle - + - + + 

c. steady amplitude obtained - + - + + 

d. Fx jitter + - - -

e. Gx + - - -

KEY: + = present 
+ — = variable 
- = absent 

Change across all dimensions is observed except for  the Fx jitter 
and Gx which remained the same for  the pre-intervention spontane-
ous speech and reading and the post-intervention conditions. Despite 
this, an alteration of  phonation mode is seen in both reading and 
in spontaneous speech following  intervention. The post-intervention 
tracings approximate normal patterns along all dimensions, apart 
from  the lengthened wave base. This additional feature  on the post-

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48 Marlene Behrmann 

intervention tracings is not unusual since Metz, Onufrak  and Og-
bum (1979) observed that post-therapy speech may be fluent  despite 
the addition of  certain temporal characteristics. It must be borne 
in mind that the therapy program was not entirely complete at this 
stage and thus the timing element was not yet habituated. 

It was also interesting to note that the results of  the Erickson atti-
tude scale taken after  the therapy program showed change as a score 
of  9.2 was obtained. Hayhow (1983) has proposed that therapy con-
tinue until an S24 score of  ten or less (for  males) is achieved as 
was done in the present study. 

Of  interest, too, is the comparison of  the post-intervention frequency 
and severity ratings with the pre-intervention scores. The post-
intervention %SS and SPM are presented in Figure 3 for  compari-
son with the pre-intervention assessment. A post-intervention reduc-
tion in %SS is evident across all conditions and the post-intervention 
%SS count falls  within the normal limit of  6,5%SS as specified 
by Andrews and Ingham (1971). The telephone condition produced 
the highest %SS both pre- and post-intervention, a finding  which 
supports the observation of  Leith and Timmons (1983) that the 
telephone is the most difficult  situation for  stutterers. 

spontaneous reading 
speech 

SAMPLING CONDITIONS 

KEY: 
Ξ PRE 
• POST 

Figure 3 Mean percentage syllables stuttered across all conditions 
pre- and post-intervention 

A minimal increase in SPM was noted from  pre- to post-intervention 
speech sampling (See Figure 4). The post-intervention rate of  ap-
proximately 140 SPM is slow compared to normals but may be ac-
counted for  in terms of  the stage of  therapy attained i.e. 140 SPM 
stutter free  speech under volitional control. 

| loo 
CC 

p. 7 5 
to 
IU 
m so 

s p o n t a n e o u s 
s p e e c h 

e a d i n g 

KEY: 

Η PRE 

• POST 

S A M P L I N G C O N D I T I O N S 

Figure 4 Mean syllables per minute across all conditions pre- and 
post-intervention. 

It is evident from  these results that not only did a change in laryn-
geal patterns occur but a definite  alteration of  the frequency  and 
severity of  stuttering was also noted. 

The present findings  support the contention that laryngeal distur-
bances are associated with stuttering (Conture et al. 1977; Win-
gate 1977) and that modifications  in laryngeal behaviours are 
possible through the implementation of  a continuous phonation ther-
apy program. Although it is impossible to determine whether the 
laryngeal abnormalities are the cause or effect  of  stuttering, it is 
interesting to note the relative ease with which the laryngeal dys-
function  could be remediated. It may be postulated that in accor-
dance with Schmitt and Cooper (1978), the irregular phonatory 
behaviour reflects  habituated compensatory strategies in response 
to the dysfluencies  and thus the pathology, whether neurological 
or physiological, does not 'reside' in the vocal folds  themselves. 
This suggestion, however, is speculative and further  evidence is 
indicated. 

This case study has highlighted the benefits  of  a fluency  inducing 
therapy program and has revealed the alteration in the laryngeal 
behaviour and the change in frequency,  severity and rate of  the stut-
ter pattern. Furthermore, it illustrates the necessity for  in-depth base-
line evaluation of  the stutter pattern in order to estimate the efficacy 
of  a therapy program. In addition, the applicability of  the elec-
trolaryngograph as a measurement tool for  assessing and monitor-
ing change in the vocal fold  vibration of  a stutterer is illustrated. 
Whereas traditionally, phonatory behaviours of  stutterers were 
measured through the use of  rating scales and other subjective 
means, the electrolaryngograph has been shown to be a useful  and 
objective assessment tool for  evaluating vocal fold  behaviours. 

CONCLUSIONS AND IMPLICATIONS 

This study was directed to the objective evaluation of  laryngeal be-
haviour pre- and post-intervention in an adult stutterer, the inter-
vention being in the form  of  a fluency-based  program designed to 
modify  phonatory pattern and to reduce rate. The results revealed 
a marked difference  between the laryngographic tracings in the two 
conditions. This difference  was evident along several dimensions 
such as regularity, shape of  the waveform,  and ease with which 
steady amplitude is achieved, Gx and Fx. In addition to this, the 
results demonstrated a decrease in the frequency  and severity of 
stuttering during reading, spontaneous speech and the telephone sit-
uation. A positive change in the subject's attitude was also noted. 

Several clinical and theoretical implications are evident. These per-
tain not only to this particular subject or to stutterers in general, 
but also to the measurement techniques employed in this study! With 
regard to the subject of  the present study, long-term follow!  up to 
assess the therapeutic gains is indicated and, indeed, the use of  the 
electrolaryngograph to evaluate long-term outcome should prove 
informative.  The utilization of  the electrolaryngograph with other 
stutterers in an attempt to identify  and describe the deviant phona-
tory pattern should prove interesting. Furthermore, the electrolaryn-
gograph may be utilized in conjunction with techniques for  the 
assessment of  the respiratory and articulatory mechanism of  the stut-
terer. Interactions between these systems have been reported (Adams 
1974) and the evaluation of  these should provide interesting infor-
mation. Future research in these areas should contribute to the in-
creasing amount of  information  in this field  and consequently, 
therapeutic intervention should improve. 

ACKNOWLEDGEMENT 

The writer wishes to thank Professor  A. Traill, Department of  Lin-
guistics, University of  the Witwatersrand, Johannesburg, for  his 

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Laryngeal Behaviour and Fluency-inducing Therapy 

assistance in the administration and interpretation of  the electrolaryn-
gographic tracings. 

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Hearing Aid Centre S.A. (Pty) Ltd 
ESTABLISHED IN 1949 

Offers 
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Comprehensive wide range of  modern 
hearing aids 
Complete service facilities 
Modern range of  audiometric and allied 
equipment 
Own earmould laboratories 
In fact  - everything that the audiologist may 
require 

COUNTRY-WIDE SERVICE 
AND FULLY EQUIPPED OFFICES AT 

J o h a n n e s b u r g (Head Office) 
Hearing Aid Centre S.A. (Pty) Ltd 
212 Harley Chambers 
187 Jeppe Street 
JOHANNESBURG 2001 
Telephones: 337-2643/4/5 

Pretoria 
Hearing Aid Centre S.A. (Pty) Ltd 
633 Kerkade Centre 
267 Church Street 
PRETORIA 0002 

Cape T o w n 
Hearing Aid Centre S.A. (Pty) Ltd 
104 Cartwright's  Corner 
c/o Adderley & Darling Streets 
CAPE TOWN 8001 

Telephones: 21-7245/6 Telephone: 46-5816 

The  South  African  Journal  of  Communication  Disorders,  Vol.  32, 1985 

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