THE EFFECT OF DIFFERENT BREATHING TECHNIQUES ON STUTTERING THERAPY OUTCOME & RESISTIVE EXERCISES FOR ADULTS WITH SEVERE STUTTERING

2014 Study: 35 Children

Comparing 5 different inhalation modes • Best result: Intensive prolonged nasal inhalation • 29/35 achieved fluent speech • 100% maintained at 3 months

Resistive Exercises: 18 Adults

Static vs Dynamic exercises • 9 subjects each • Static: speech speed 94→108 syll/min, spasms reduced • Dynamic: no significant changes

👩‍🔬 Nabieva T.N. Ph.D., SLT, neurophysiologist

Brain Research Department of Scientific Neurology Center,
Russian Academy of Medical Sciences, Moscow

ВЛИЯНИЕ РАЗЛИЧНЫХ ТЕХНИК ДЫХАНИЯ НА РЕЗУЛЬТАТ ТЕРАПИИ ЗАИКАНИЯ И РЕЗИСТИВНЫЕ УПРАЖНЕНИЯ ДЛЯ ВЗРОСЛЫХ

2014: 35 детей

5 типов вдоха • Лучший: интенсивный носовой • 29/35 достигли плавной речи • 100% через 3 месяца

Резистивные: 18 взрослых

Статика vs Динамика • Статика: темп 94→108 сл/мин, спазмы уменьшены • Динамика: без изменений

👩‍🔬 Набиева Т.Н. к.б.н., логопед, нейрофизиолог

Отдел исследований мозга, Научный центр неврологии,
Российская Академия Медицинских Наук, Москва

🌬️ 2014 BREATHING STUDY: COMPLETE DATA

Background: Various breathing modifications used in stuttering treatment

References: Andrews & Tanner, 1982; Azrin & Nunn, 1973,1974; Azrin et al, 1979; Falkowski et al, 1982; Hasbrouck, 1992; Lee, 1976; Schwartz, 1976; Perkins, 1973; Wagaman et al, 1993

Techniques include: regulated breathing, control of breathing, breath stream management, airflow therapy, graded airflow, deep breathing

Purpose

To discover the optimal speech-related respiratory behavior for stuttering therapy, we undertook the investigation where stuttering children used different respiration models during the therapy course.

Method

35 children

2;3;4-13 years old

5 groups

1 month course

1/week sessions with speech therapist • Daily 1 hour treatment sessions with parents • Speech control

Participants were divided into groups according to speech-related inhalation mode:

1. Quiet brief nasal inhale

2. ⭐ Intensive prolonged nasal inhale ⭐ BEST RESULTS

3. Quiet prolonged nasal inhale

4. Intensive prolonged mouth inhale

5. Intensive brief mouth inhale

Treatment Protocol for Best Group

1/week therapeutic sessions
Daily 1 hour treatment sessions with parents
Speech control throughout

Results - Intensive Prolonged Nasal Inhalation Group

Completion Rate

29 completed treatment, achieving fluent speech

6 children interrupted treatment

Treatment Time

Individual: 2-6 months

Dependent on: stuttering experience, age, gender, stuttering severity

Follow-up Results

First month post-treatment: 4 children had single stuttering episodes, successfully eliminated

After 3 months: All 29 subjects maintained fluent speech

Why nasal inhalation is more effective? Animal Studies

References: Adrian, 1950; Arduini Moruzzi, 1953; Gault & Coustan, 1965; Servit & Strejckova, 1978,1979; Servit et al, 1981; Tsubone, 1989; Ueki & Domino, 1961.

Intensive air passing through nasal cavity of lower vertebrates elicit synchronous theta-activity in:

🧠 bulbus olfactorius

🧠 hippocampus

🧠 pyriform cortex

🧠 amygdale

🧠 thalamus

🧠 general cortex

Studies on animals revealed flow receptors in nasal mucosa. Afferent fibers connected to mechano-sensitive nasal endings extend to trigeminal nerve.

EEG Study in Humans

8 healthy adult volunteers • EEG recording (14 bipolar leads) • 3 experimental conditions:

3 minutes quiet respiration (baseline)
3 minutes mouth hyperventilation (15 breaths/minute)
3 minutes nasal hyperventilation (15 breaths/minute)

Baseline theta-activity did not change in response to neither nasal nor oral hyperventilation

0-40 - averaged meanings of theta-band power spectrum. F, C, T, P, O - leadings

Key Finding

Changes in brain bioelectric activity are conditioned by the volume of ventilated air, but not the breathing pathway (nasal or mouth).

Maximal attainable frequency of nasal hyperventilation was limited to about 15 breaths/min due to higher translyngeal inspiratory and expiratory resistance during nasal breathing. Such hyperventilation couldn't lead to hypocapnia that evokes EEG changes.

Conclusion: Better results of stuttering treatment with intensive nasal inhalations couldn't be explained by specific effect of nasal respiration on central nervous system.

What is the difference between nasal and mouth inhalations?

👄 Mouth inhalation:

❌ relax the larynx and the pharynx
❌ dilate the larynx and the pharynx
❌ relax and abduct vocal chords
❌ lowers the larynx

Vennard, 1967; Hirano et al, 1969; Rubin et al, 1967; Basner et al, 1989; Tangel et al, 1995

👃 Nasal inhalation:

✅ induce glottal constrictors activity
✅ strain, contract and narrow the pharynx and larynx
✅ adduct vocal chords
✅ increase muscle tension of diaphragm and neck
✅ increase respiratory resistance

Jouneaux et al, 1995; Moreau-Bussière et al, 2007; Mukai, 1989; Song & Pae, 2001; Tangel et al, 1995; Yong-Xin Shi et al, 1998

Hypothesis: Strength Training Effect

We suppose extensive muscle load during nasal inhalations acts in the capacity of strength training

Adkins, 2002; Andersen et al, 2006; Comery et al, 1995; Enoka, 1996; Häkkinen & Komi, 1983; Greenough et al, 1985; Jones et al, 1999; McDonagh & Davies, 1984; Pucci et al, 2006; Kleim et al, 1996,2002; Swain et al, 2003; Withers & Greenough, 1989

Strength training produces:

📈 increases in muscular growth and strength
⚡ neuromuscular activation
🧠 cortical angiogenesis and synaptogenesis
🔄 alterations in neuromuscular transmission
🎯 changes in sensitivity of muscle spindles

Implications for stuttering:

Regular vigorous muscle work strengthens speech related muscles
Changes in muscle spindle sensitivity raise thresholds of neuromuscular excitation
Compulsive efferent stimuli turn into subthreshold exciters
Reduction of pathological involuntary activity
Decreasing stuttering severity

Acknowledgements (2014)

Special thanks to:

All participants of the study
Dr Derevyagin VI, biostatistic
Dr Bazyian BKh, Dr Damyanovich EV
Director Natalie Kaminsky, and staff of English Nursery School "Magic Castle"
Cristal Williams and Robert Hartley

🌬️ 2014 ИССЛЕДОВАНИЕ ДЫХАНИЯ: ПОЛНЫЕ ДАННЫЕ

Предпосылки: различные модификации дыхания в терапии заикания

Литература: Andrews & Tanner, 1982; Azrin & Nunn, 1973,1974; Azrin et al, 1979; Falkowski et al, 1982; Hasbrouck, 1992; Lee, 1976; Schwartz, 1976; Perkins, 1973; Wagaman et al, 1993

Методики: регулируемое дыхание, контроль дыхания, управление воздушной струей, терапия воздушным потоком, градуированный воздушный поток, глубокое дыхание

Цель

Определить оптимальный речевой дыхательный паттерн для терапии заикания. В исследовании дети с заиканием использовали разные модели дыхания.

Метод

35 детей

2;3;4-13 лет

5 групп

1 месяц

1 занятие в неделю с логопедом • Ежедневные 1-часовые занятия с родителями • Контроль речи

Группы по типу вдоха:

1. Тихий короткий носовой вдох

2. ⭐ Интенсивный продолжительный носовой вдох ⭐ ЛУЧШИЙ РЕЗУЛЬТАТ

3. Тихий продолжительный носовой вдох

4. Интенсивный продолжительный ротовой вдох

5. Интенсивный короткий ротовой вдох

Результаты - Интенсивный носовой вдох

Завершили лечение

29 достигли плавной речи

6 прервали лечение

Время лечения

Индивидуально: 2-6 месяцев

Зависит от: стажа заикания, возраста, пола, тяжести

Катамнез

Первый месяц: у 4 детей единичные эпизоды, успешно устранены

Через 3 месяца: все 29 сохранили плавную речь

Почему носовой вдох эффективнее? Исследования на животных

Интенсивное прохождение воздуха через носовую полость вызывает синхронную тета-активность в обонятельной луковице, гиппокампе, грушевидной коре, миндалине, таламусе, коре. Обнаружены рецепторы потока в слизистой носа.

ЭЭГ исследование на людях

8 здоровых взрослых, 14 отведений, 3 условия: тихое дыхание, гипервентиляция ртом (15/мин), гипервентиляция носом (15/мин).

Тета-активность не менялась. Изменения зависят от объема воздуха, а не пути дыхания.

Разница между носовым и ротовым вдохом

👄 Ротовой вдох:

расслабляет гортань и глотку
расширяет гортань
расслабляет голосовые складки
опускает гортань

👃 Носовой вдох:

активирует констрикторы гортани
сужает глотку и гортань
приводит голосовые складки
увеличивает напряжение диафрагмы
повышает дыхательное сопротивление

💪 RESISTIVE EXERCISES FOR ADULTS WITH SEVERE STUTTERING - COMPLETE DATA

Introduction - Stuttering is accompanied by abnormal activity of speech related muscles

Stutterers demonstrate involuntary spasmodic movements:

of the tongue, the larynx and the vocal folds at the moment of the intention of speaking (Freeman & Ushijima, 1978; Monfrais-Pfauwadel et al, 2005).

EMG abnormalities:

During dysfluent speech the jaw, the lip and laryngeal muscles of stutterers show rhythmic tremor-like oscillations of EMG activity (Kelly et al, 1995; Smith, 1989; Smith et al, 1993).

Respiratory dyscoordination:

Speech in stutterers is characterized by chaotic contractions of the diaphragm, rib cage and abdominal muscles singly or in various combinations (Zocchi et al, 1990).

Stuttering is associated with dyscoordination of different muscle systems

Dyscoordination and asynchrony:

of lip, tongue, and jaw muscles (McClean & Runyan, 2000; Zimmermann, 1980).

Disruption of normal interaction:

between laryngeal, articulatory, and respiratory systems (Conture et al, 1985; Freeman & Ushijima, 1978).

Severe stuttering observations:

In the cases of severe stuttering all above mentioned symptoms aggravate and intensify. Moreover, in some cases of severe stuttering we observed specific for every patient complexes of involuntary movements, forestalling speech initiation. It could include prolonged (2-8 sec) spasms or perseverative labial, mandibular movements and vocal ticks. As far as pathologic muscular activity appears to be one of the fundamental elements of the stuttering pathogenesis, it seems logical to employ muscle exercises to influence stuttering symptoms. Thereby the purpose of this investigation was to evaluate the therapeutic effects of 1) conventional dynamic orofacial exercises and 2) static resistive orofacial exercises in adult patients with severe developmental stuttering.

Method - Complete Protocol

🧘 Static exercises group

9 subjects (1 female, 8 male)
Mean age 32 years
Mean %SS - 24 %SS
3 weeks of static exercises
3 clinical sessions
Daily training sessions (60-90 minutes)
9 sets of exercises: 3 for tongue, 3 for lips, 3 for neck/larynx
1 set = 10 exercises
1 exercise = 10-60 seconds hold

🏃 Dynamic exercises group

9 subjects (2 female, 7 male)
Mean age 30 years
Mean %SS - 21 %SS
3 weeks of dynamic exercises
3 clinical sessions
Daily training sessions (60-90 minutes)
9 sets of exercises: 3 for tongue, 3 for lips, 3 for neck/larynx
1 set = 50 exercises
1 exercise = 1-3 seconds

🗣️ Complete Exercise Protocol Visualization

Static exercises for tongue (10-60s each)

Dynamic exercises for tongue (10-60s each)

Static exercises for lips (10-60s each)

Dynamic exercises for lips (10-60s each)

Static exercises for larynx (10-60s each)

Dynamic exercises for larynx (1-3s each)

Results

Static exercises group:

📈 Speech speed: 94 → 108 syllables/minute (p<0.01, Wilcoxon matched pairs test)

📉 Amount of prolonged spasms (>2 sec) significantly reduced (p<0.001)

📉 Complexes of involuntary movements before speech initiation significantly reduced

📉 % syllables stuttered significantly decreased, maintained at 3 weeks follow-up (p<0.01)

Dynamic exercises group:

➖ No significant change in speech speed

➖ No influence on muscle spasms

➖ No influence on stuttering severity

Discussion - Neural Adaptations to Resistive Training

Muscle adaptations:

Isometric resistance exercises induce neuromuscular activation
Stimulate muscle growth and strength (Andersen et al, 2006; Pucci et al, 2006)
Elevated muscle protein synthesis 4-24h postexercise (Chesley et al, 1992)
Satellite cell activation, hyperplasia, fiber type changes (Folland & Williams, 2007)

Cortical adaptations:

Cortical angiogenesis (Kleim et al, 2002; Swain et al, 2003)
Dendritic and synaptic hypertrophy
Synaptogenesis within motor cortex, cerebellum, striatum
Adkins, 2002; Comery et al, 1995; Greenough et al, 1985; Jones et al, 1999; Kleim et al, 1996,1997a,b; Withers & Greenough, 1989

Motoneuron adaptations:

Dendrite restructuring
Increased protein synthesis
Enhanced neuromuscular transmission dynamics
Changes in electrophysiological properties of alpha-motoneurons (Gardiner et al, 2006)

Clinical implications:

Changes in muscle spindle sensitivity raise thresholds of neuromuscular excitation
Compulsive efferent stimuli become subthreshold
Amount of pathological involuntary movements decrease
Normalize muscle tonus

Conclusions - Resistive Exercises Study

✅ Static resistive exercises appear to be an effective treatment option for decreasing stuttering severity in adult patients
✅ Most important outcome: shortening and attenuating prolonged muscle spasms
⚠️ Changes in %SS and speech speed are not substantial enough to consider exercise training as independent therapeutic procedure
⭐ For more than 20 years we are successfully applying suggested exercises as treatment element for preliminary period of stuttering rehabilitation
⭐ It facilitates subsequent treatment, increases its effectiveness and decreases treatment time

Acknowledgments - Resistive Exercises

The author thanks the participants; staff and chiefs (Tykhonova TY and Romanova OS) of the Khamovniky Social Service Center; Dr Derevyagin VI for statistical contributions.

💪 РЕЗИСТИВНЫЕ УПРАЖНЕНИЯ ДЛЯ ВЗРОСЛЫХ - ПОЛНЫЕ ДАННЫЕ

Введение - Заикание сопровождается аномальной активностью речевых мышц

Непроизвольные спазмы языка, гортани, голосовых складок в момент намерения говорить
Тремороподобные осцилляции ЭМГ в челюстных, губных и гортанных мышцах
Хаотичные сокращения диафрагмы, грудной клетки и мышц живота

Метод - Полный протокол

Статическая группа

9 чел (1 ж, 8 м), средний возраст 32, 24%SS
3 недели статических упражнений
3 клинических занятия
Ежедневные тренировки 60-90 мин
9 комплексов: язык, губы, гортань/шея
1 комплекс = 10 упражнений
1 упражнение = 10-60 сек удержания

Динамическая группа

9 чел (2 ж, 7 м), средний возраст 30, 21%SS
3 недели динамических упражнений
3 клинических занятия
Ежедневные тренировки 60-90 мин
9 комплексов
1 комплекс = 50 упражнений
1 упражнение = 1-3 сек

Результаты

Статическая группа:

📈 Темп речи: 94 → 108 сл/мин (p<0.01)

📉 Длительные спазмы (>2 сек): значительное уменьшение (p<0.001)

📉 % заикающихся слогов: значительное снижение (p<0.01)

Динамическая группа:

➖ Без значимых изменений

Выводы

Статические резистивные упражнения эффективны для снижения тяжести заикания у взрослых
Главный результат: уменьшение длительных мышечных спазмов
Более 20 лет успешно применяем как подготовительный этап реабилитации
Облегчает последующее лечение, повышает эффективность, сокращает время

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📚 ПОЛНЫЙ СПИСОК ЛИТЕРАТУРЫ (70+ источников)

Adkins, 2002 - Пластичность моторной коры
Andersen et al, 2006 - Нейромышечная активация
Andrews & Tanner, 1982 - Регулируемое дыхание
Azrin & Nunn, 1973-1979 - Техники дыхания
Basner et al, 1989 - Мышцы верхних дыхательных путей
Comery et al, 1995 - Плотность дендритных шипиков
Conture et al, 1985 - Поведение гортани
Del Balso & Cafarelli, 2007 - Тренировка сопротивления
Duchateau & Hainaut, 1984 - Изометрические vs динамические
Enoka, 1997 - Нейронные адаптации
Falkowski et al, 1982 - Терапия воздушным потоком
Folland & Williams, 2007 - Адаптации к силовым тренировкам
Freeman & Ushijima, 1978 - Активность гортани
Gardiner et al, 2006 - Альфа-мотонейроны
Gault & Coustan, 1965 - Носовой поток и ЭЭГ
Greenough et al, 1985 - Ветвление дендритов
Griffin & Cafarelli, 2005 - Адаптации двигательных единиц
Häkkinen & Komi, 1983 - Мышечные веретена
Hasbrouck, 1992 - Интенсивное лечение
Hirano et al, 1969 - Функция гортани
Jones et al, 1999 - Пластичность моторной коры
Jouneaux et al, 1995 - Реакция голосовой щели
Kleim et al, 1996-2002 - Кортикальная пластичность
Lee, 1976 - Техника воздушного потока
McDonagh & Davies, 1984 - Адаптация мышц
McClean & Runyan, 2000 - Скорость орофациальных движений
Monfrais-Pfauwadel et al, 2005 - События в гортани
Moreau-Bussière et al, 2007 - Реакция гортани
Mukai, 1989 - Гортанная дизосмия
Perkins, 1973 - Замещение заикания
Pucci et al, 2006 - Частота разряда двигательных единиц
Rubin et al, 1967 - Интенсивность голоса
Sale, 1988 - Нейронная адаптация
Servit & Strejckova, 1978-1979 - Тета-активность
Smith, 1989-1993 - ЭМГ при заикании
Song & Pae, 2001 - Активность орофациальных мышц
Swain et al, 2003 - Ангиогенез при упражнениях
Tangel et al, 1995 - Контроль дыхательных мышц
Tsubone, 1989 - Рецепторы носового потока
Ueki & Domino, 1961 - Обонятельные рецепторы
Vennard, 1967 - Вокальный механизм
Wagaman et al, 1993 - Лечение заикания
Withers & Greenough, 1989 - Моторная кора
Yong-Xin Shi et al, 1998 - Мышцы верхних дыхательных путей
Zimmermann, 1980 - Динамика артикуляции
Zocchi et al, 1990 - Дыхательные мышцы

📄 Breathing Techniques 2014 📄 Техники дыхания 2014 💪 Resistive Exercises 2012 💪 Резистивные упражнения 2012 ⚠️ Main risk factors for the stuttering onset ⚠️ Основные факторы риска возникновения заикания

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