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RESEARCH PROPOSAL:

Can Stuttering Blocks Be Controlled by Relaxation of the Valsalva Mechanism?

by William D. Parry, Esquire

(A research proposal presented by Bill Parry at a Stuttering Research Symposium sponsored by the National Stuttering Association in Anaheim, CA, on June 26, 2002.)

The Hypothesis:

The excessively forceful closures of the mouth or larynx associated with certain types of stuttering, as well as difficulty in phonation, may involve a neurological confusion between speech and the human body's Valsalva mechanism. This mechanism, consisting of neurologically coordinated muscles in the mouth, larynx, chest, and abdomen, is designed to increase pulmonary pressure by forceful closure of the upper airway to assist in many types of physical effort and in forcing things out of the body (the Valsalva maneuver).

Stuttering blocks may involve excessive neuromotor tuning of the Valsalva mechanism prior to speech, especially in situations where the stutterer anticipates difficulty or feels the need to use extra effort to speak properly. Such tuning may:

render the Valsalva mechanism over-excitable to triggering stimuli, such as the increase in subglottal pressure that accompanies the start of articulation;

interfere with normal prephonatory tuning of the vocal folds (because the larynx is instead being neurologically tuned for effort closure), thereby causing delays and difficulty in phonation; and

contribute to abnormal laryngeal behavior, either by increasing the strength of laryngeal reflexes (the Valsalva maneuver is known to strengthen reflexes), or by interfering with the suppression of reflexes, which normally occurs during speech.

The ordinary Valsalva maneuver involves tight closure of the vocal and vestibular folds of the larynx (called effort closure) for the purpose of sealing off the respiratory tract, accompanied by contraction of the parietal muscles of the abdomen and thorax. The various elements of the Valsalva mechanism appear to be linked neurologically so that they tend to contract simultaneously. The force of the closure is in proportion to the amount of pulmonary air pressure being resisted.

However, the forceful closures associated with a Valsalva maneuver need not be limited to the usual effort closure of the larynx, but may instead involve tight closure of the lips or tongue, depending on which structure initiates blockage of the airway. Consequently, forceful closure of the lips and tongue may occur during the articulation of certain consonants, while forceful closure of the larynx may occur during the initial articulation vowel sounds (known as coup de glotte or "glottal attack" and sometimes referred to as "hard onset").

The fluency-enhancing effects of many speech therapies may be attributed to their indirect effects on the Valsalva mechanism - such as by utilizing light contacts in articulation, easy onset of vowel sounds, emphasis on phonation, release of air prior to speaking, breathing techniques, etc. However, none of them focuses directly on controlling the Valsalva mechanism.

It is therefore proposed that the frequency and severity of stuttering blocks may be reduced by teaching the person who stutters to relax his or her Valsalva mechanism while speaking. This relaxation of the Valsalva mechanism might be accomplished by:

Relaxation of the abdominal and rectal muscles, which will tend to relax all the other parts of the Valsalva mechanism, including the oral and laryngeal muscles used to block the upper airway. This may include exercises in:

Relaxing the abdomen as one exhales and begins speaking.

"Voluntary Valsalva," involving intentional blocks using the Valsalva maneuver, which are then released by relaxing the abdomen.

Speaking exercises designed to tune the larynx for phonation rather than effort closure, as well as teaching the person to treat words as sequences of movements, rather than as "things" to be forced out of the body.

Education about the Valsalva mechanism, understanding why forcing is counter-productive even though it "feels" like the right thing to do, and attitudinal changes to reduce the urge to use force and effort in speaking.

Background

The Valsalva Hypothesis, first proposed in my 1985 article in the Journal of Fluency Disorders cited below, was based on my extensive review of medical and stuttering research literature and my own personal experimentation - including a nasopharygoscopic study performed on me at Pennsylvania Hospital in Philadelphia. By understanding the Valsalva mechanism and learning to control it through various exercises (which I refer to as "Valsalva Control"), I had overcome a severe stuttering problem to such an extent that I was able to function effectively as a trial lawyer. Since then, my level of fluency has continued to improve.

In 1985 I founded the Philadelphia Area Chapter of the National Stuttering Project (now the National Stuttering Association), and served as its Chapter Leader for 15 years. I have also served on the Board of Directors of the NSA for six years (1996-2002) and have presented numerous workshops on the Valsalva Hypothesis at NSP/NSA conferences and international conferences.

In reviewing a presentation I gave at a Speak Easy Int'l symposium in 1986, J. David Williams, Ph.D. (then of Northern Illinois University), wrote in the Speak Easy newsletter:

"[The Valsalva Hypothesis] is of potentially significant scientific value in explaining the nature of stuttering behavior. . . . Though not a speech pathologist, Bill Parry has a trained, precise mind . . . and makes a meaningful plea for research to confirm or refute the Valsalva hypothesis." [Emphasis added.]

I continued to research the medical and stuttering literature and to test my ideas informally on myself and members of the Philadelphia Area Chapter and at numerous workshops. I published a book, Understanding & Controlling Stuttering: A Comprehensive New Approach Based on the Valsalva Hypothesis, cited below, which is now in its second edition. For more than a year it has been the National Stuttering Association's best-selling book and the best-selling book about stuttering on Amazon.com.

In 1995 I was invited to give a major presentation on the Valsalva Hypothesis at the World Congress for People Who Stutter, in Linköping, Sweden. I subsequently placed this paper, "The Valsalva Mechanism: A Key to Understanding Stuttering Behavior", on the Internet .

Discussion

I view the Valsalva mechanism as only one piece in the complex stuttering puzzle. But I consider it to be a very important piece, because it helps to link many of the other pieces together. If confused with speech, this normal bodily function might cause excessively forceful closures of the mouth or larynx and delays in phonation — two of the basic symptoms of stuttering. The many other varieties of stuttering behavior could then be explained as attempts to avoid, postpone, or conceal these underlying blocks.

The Valsalva Hypothesis suggests why we may instinctively block airflow and build up air pressure in an attempt to force out words as if they were "things." It explains why this feels like the necessary thing to do — even though it makes fluent speech impossible. Therefore, the harder one struggles against stuttering, the worse the blocks become. It may explain why stuttering occurs in some situations more than others, and why it usually hits hardest on the most important words.

Other factors may also fit into this picture, insofar as they contribute to the anticipation or perception of difficulty. For example, some stutterers' speech might be affected, to varying degrees, by neurological impairments or emotional problems. Even when the initial difficulty is due to a neurological weakness, the Valsalva Hypothesis may describe the individual's learned reaction, which may greatly aggravate the symptoms.

A child's original disfluencies may be caused by a variety of neurological, psychological, or developmental factors not involving the Valsalva mechanism. These original causes may be different for various individuals, but their commonality is that they create the perception that speech is difficult and will require extra physical effort. A child's effortless, whole-word repetitions might gradually progress into forceful blockages, bringing the Valsalva mechanism into play. The child — already accustomed to using the Valsalva maneuver when exerting effort or expelling bowel movements — may instinctively assume that words can be forced out in the same way.

Continuation of this behavior during certain critical years of childhood may influence the development of nerve pathways in the brain. The pathways linking speech to the Valsalva mechanism might be strengthened by constant use, while those for fluent speech may remain underdeveloped. Over time, these behaviors become deeply rooted in the nerve pathways of the brain, making them extremely difficult to change. Consequently, there may be some connection between certain anomalies found in stutterers' brain function, as seen on PET scans, and their tendency to confuse speech and the Valsalva mechanism.

The physiological effects of the Valsalva mechanism have long been known to the medical profession - and even to players of brass musical instruments - but they have been inexplicably ignored by the SLP profession. Nevertheless, there is growing anecdotal evidence that understanding and controlling the body's Valsalva mechanism may be highly beneficial in reducing the severity of stuttering blocks.

My Internet article and my book have both drawn hundreds of favorable e-mails from stutterers all over the world. They repeatedly state that, after years of unsuccessful stuttering therapy, the Valsalva Hypothesis is the first theory that precisely describes their stuttering experience and makes any sense to them. A number of those responses appear in the appendix attached to this proposal.

Examples of Valsalva Control

Rather than teaching a new way to speak, Valsalva Control is aimed at recognizing and controlling the physiological forces that interfere with speech. The following are some simple demonstrations of the possible benefits of Valsalva Control (there are many others).

At my NSA workshops and chapter meetings, I have repeatedly demonstrated that the sure way to release the blockages in the mouth or larynx is to relax the abdominal muscles. I have asked attendees to make the strongest block they can - such as with their lips on the "p" sound - and notice where the muscular tension is. They all find that, in addition to the mouth, there is great tension in the abdominal muscles. Then, while they are making the block, I ask them to relax their abdomen. To their surprise, the blocking in the mouth automatically disappears! They find that they cannot maintain a forceful block in the mouth or larynx while they are relaxing the abdominal muscles.

This is because the muscles that block the upper airway (including the lips and tongue as well as the larynx) are neurologically coordinated with the abdominal muscles as part of the Valsalva mechanism. Relaxing the abdomen relaxes the Valsalva mechanism, which automatically removes the force behind the blockage in the mouth or larynx.

Consequently, the most efficient and effective way to reduce or prevent the forceful blockages of the mouth and larynx during speech would be to learn to relax the Valsalva mechanism. However, this principle is almost never taught in speech therapy. Current stuttering therapy is often aimed at removing the muscular tension that occurs in the lips, tongue, and larynx during stuttering blocks - as if these are isolated behaviors - without addressing the physiological force that is behind the blocks. Trying to relax the muscles of the mouth and larynx independently will be of little value if the Valsalva mechanism remains out of control.

Although I don't claim it to be a panacea, I have found the simplest and most effective Valsalva Control technique to be as follows:

Take a full breath;

relax your abdomen as you exhale, and

coordinate speech with the relaxation of your abdomen.

Let relaxation of the abdomen be the act that controls your speech. Concentrate on relaxation of your abdomen and totally forget about what your mouth is doing. It may help to pretend that you are instead talking through your navel.

This technique has been very effective in increasing fluency at the informal workshops I have conducted. One gentleman recently reported that, after learning the technique at a workshop, he used it when reading aloud to his grandchildren and was amazed at how it eliminated the tension he previously had felt in his mouth and larynx.

I fully recognize that stuttering is a complex condition, with many interacting factors that vary greatly depending on the individual. Therefore, my suggestions regarding Valsalva Control are much more comprehensive and holistic than the simple exercise I just described. In some situations, a stutterer's urge to force is so great that it may be difficult to relax the abdomen. Therefore, this technique by itself should not be seen as an instant "cure," but simply one part of a comprehensive learning process.

The Need for Research

Stuttering is a complex and multi-faceted condition, to which many different research and therapy approaches have been applied. However, researchers and therapists have almost completely ignored the possible involvement of the body's Valsalva mechanism - which, if properly understood, could bring immediate, practical benefits to people who stutter, for little cost and with no harmful side effects.

It is truly amazing that researchers have paid so little attention to the Valsalva mechanism, given its potential for explaining so much about stuttering. One reason, I suspect, is that they have viewed it merely in terms of the laryngeal closures that typically occur during an ordinary Valsalva maneuver. Because the larynx does not always close in this fashion during stuttering, researchers may have simply assumed that the Valsalva mechanism was not involved.

In contrast, I have taken a much broader view of the Valsalva mechanism. As I have repeatedly demonstrated with attendees my workshops and local chapter meetings, it can stimulate forceful closures in the mouth as well as the larynx. Neurological preparation for a Valsalva maneuver might also interfere with the normal prephonatory tuning of the larynx, thereby delaying phonation, as well as promoting other laryngeal reflexes that may interfere with speech.

I recognize that the Valsalva Hypothesis is still only that — a hypothesis — and that considerable scientific research is needed to establish the true role of the Valsalva mechanism in stuttering. Because I am not a speech pathologist and don't have access to a speech lab, I can't obtain this data on my own. My only avenue has been to explain my hypothesis and its ramifications as comprehensively as possible, to explore these ideas with other persons who stutter, and to try to stimulate speech pathologists to pursue the necessary research.

Because l am not licensed to do speech therapy, my first-hand experience regarding Valsalva Control is limited to myself and to informal experiments with persons attending NSA chapter meetings and at the free workshops I have conducted through our local chapter. In these settings, only the simplest and most basic techniques can be explored.

I have heard rumors about my suggestions on Valsalva Control being used successfully by various therapists, including at a hospital in Montreal and in Europe, but mainly people have used it themselves on a self-help basis. Although I have received favorable reports, it is difficult to measure success because of lack of supervision and controls.

Whether or not one accepts my hypothesis, I can see no scientific justification for refusing to investigate the Valsalva mechanism. Researchers have delved into countless aspects of stutterers' behavior and physiology — rarely on the basis of any theory that would explain as much about stuttering as the Valsalva Hypothesis.

The Importance of Speech-Language Pathologists

This brings me to one of the main reasons for this research proposal. Although some people have reported great benefit by just reading my book and applying the Valsalva Control suggestions without supervision, I believe that most people will need the help of an SLP in order to receive optimal results.

I am constantly hearing from stutterers who say that none of their speech therapy has been satisfactory, and that the Valsalva Hypothesis is the first thing that accurately described their stuttering experience or made any sense to them. I have received numerous requests for references to therapists or therapy programs that utilize Valsalva Control, but I currently have no such information. It really pains me that I can't refer them to any SLP or therapy program that will meet their needs. I understand that at least a few SLPs are using Valsalva Control. In September 2001, I received an e-mail from an SLP who bought the book and is starting to use the techniques with four high-school boys and wanted to know if there were any seminars she could attend. Unfortunately, the profession in general has totally ignored the Valsalva mechanism's possible involvement in stuttering.

I am convinced that more can be done to reduce the agony and struggle of stuttering. I personally believe that speech therapy would be much more effective if at least some elements of Valsalva Control were included. I am surprised that more SLP's do not teach the importance of relaxing and controlling the Valsalva mechanism as a part of stuttering therapy, particularly in view of the fact that Valsalva Control is:

Consistent with natural speech,

Harmless and non-invasive,

Without adverse side effects,

Without additional cost,

Easy to utilize by any SLP without the need for special equipment, and

Compatible with many existing stuttering therapy programs.

It may turn out that Valsalva Control is more suitable for some stutterers than others, but that is true for all other therapies as well. In any event, this option should be a boon to most SLPs - many of whom are at their wit's end trying to find an effective approach to treating stuttering.

Therefore, I encourage speech-language pathologists and researchers to study the Valsalva mechanism and Valsalva Control as a means of better understanding and controlling stuttering blocks. I respectfully request that this research proposal be given serious consideration.

Respectfully submitted,

WILLIAM D. PARRY

Send e-mail to: valsalvastutter@aol.com

References

Comprehensive discussions of the Valsalva Hypothesis and Valsalva Control, including references, may be found at the following:

Parry, W. D., Stuttering and the Valsalva mechanism: a hypothesis in need of investigation, Journal of Fluency Disorders, 1985, 10, 317-324.

Parry, W.D., Understanding & Controlling Stuttering: A Comprehensive New Approach Based on the Valsalva Hypothesis, 2d ed., Anaheim Hills, CA: National Stuttering Ass'n, 2000. (A copy of this book will be provided by the author, free of charge, to researchers upon request. The author receives no financial benefit from this book; profits help support the NSA or are otherwise donated.)

Parry, W.D., "The Valsalva Mechanism: A Key to Understanding Stuttering Behavior" (from my presentation at the 1995 World Congress for People Who Stutter, in Linköping, Sweden), http://members.aol.com/wdparry/valsalva.htm.

Parry, W.D., "Chapter 23: Principles of Valsalva Control", (from Understanding & Controlling Stuttering), http://members.aol.com/wdparry/chap23.htm

Responses to the Valsalva Hypothesis from Readers Who Stutter

Last modified July 5, 2002

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