Exploring the potential of Virtual Reality (VR) environemnts as a therapeutic approach to help individuals who stutter
Our Center is exploring the potential of virtual reality based environments as part of a speech therapy approach for stuttering individuals.
We are collaborating with Dr. John Tetnowski who’s a certified speech pathologist and a Professor in the Department of Communication Sciences & Disorders at OSU. A preliminary paper of our research is being presented at the Conference of American Speech-Language-Hearing Association (ASHA) (Nov 2023). A more extrensive paper will be submitted to the 2024 HCI International conference.
A summary of our work with some background information follows (they are excerpted from the paper to be presented at the 2023 ASHA conference). Our initial findings underscore the potential of such VR based therapy to help individuals who stutter.
What is Stuttering
• It’s a Fluency disorder marked by specific disfluencies:
• Part word repetitions (b-b-b-b-ball), prolongations (liiiiiiiiike), and blocks (…………….dog).
• These are marked by physical, emotional, and biological associated behaviors:
• Physical: (e.g., grimacing, eye blinking, foot tapping)
• Emotional: (e.g., anxiety, stress, anger, loss of control)
• Biological: (e.g., increased heart rate, skin conductance)
Iceberg Analogy
Major philosophies of treatment
• Fluency Shaping
• Seek to eliminate stuttering through changing ALL speech to a method that is incompatible or less compatible with stuttering (e.g., prolonged speech)
• Stuttering Modification
• Help clients to stutter more easily through awareness and reduction of tension to ultimately change moments of stuttering (e.g., cancellations, pullouts)
• Acceptance of Stuttering
• Learning to live a fulfilled life while still stuttering and placing emphasis on spontaneous communication (e.g., disclosure, pseudostuttering)
Current Problems with Treatment
• All programs struggle to generlize techniques outside of clinic settings
• Currently done with trips/visits to natural settings or role play activities
• Each as their own drawbacks
• Craig (2002) has shown that relapse following stuttering treatment may be as high as 90%
• We believe that successful therapy occurs when the client is able to effortlessly assimilate their strategies in all settings and continually be reinforced with positive reactions and outcomes (Brundage, 2004)
Why this Line of Research?
• Evidence show that treatment is currently difficult to generalize
• Lack of generalizability will limit the benefits of therapeutic tools
• Continuing negative reactions in real life scenarios
• Resulting in adverse effects on a person’s life
Virtual Reality (VR) applications in related areas
• VR is a tool that can bridge the gap between clinic-based and real-life settings
• VR has been used in many applications
• Military
• Flight simulators
• Teaching veterinarians how to examine animals (Cecil et al.,
• Teaching STEM subjects to students (Cecil et al.,
• ASD populations (Cecil et al.,
• Potential to create opportunities for People who Stutter (PWS) to practice using their modifications in typical scenarios
Limited Virtual Reality & Stuttering
• Brundage (2006) studied 23 adults in interview setting
• Al-Nafjan (2021) studied 3 adults in a presentation setting
• Both produced positive findings but:
• VR was used only in a laboratory setting
• VR was used only with adult participants
• Past studies only talked about feelings, but did not measure any biological marker
• Advantageous if VR technology could be used in the convenience of their home
Summary
• Difficulty generalizing stuttering therapy techniques outside the clinic
• Virtual reality presents opportunities to bridge the gap between the clinic and real-life scenarios
• Evidence shows positive impacts of VR in the treatment of stuttering
• Purpose of this preliminary study: to test the efficacy of a portable and relatively low-cost VR system to promote continued learning and carryover outside of the traditional therapy room in VR environments
Three Research Questions
1. What is the impact on stuttering skills following an at-home trial program using VR simulations?
2. What is the impact on affective and cognitive feelings following an at-home trial program using VR simulations?
3. What are the lived experiences of the PWS following an at-home trial program using VR simulations?
Participants
• 4 adolescents that stutter
• Age range: 9-12 years old
• 3 male and 1 female
• Participants were recruited from a local self-help group and through contacts with the Oklahoma State University Speech, Language and Hearing Clinic
• All procedures were approved by the Oklahoma State University IRB
Procedures: Pre-test
• An explanation of the goals of this project and expectations
• A demonstration of the VR setting and how the device works
• Calculation of %SS while using the VR simulations
• Completion of the Stuttering Severity Instrument – 4 (SSI-4) (Riley, 2009)
• Completion of the Overall Assessment of the Speaker’s Assessment of Stuttering (OASES; Yaruss and Quesal (2008)
• Completion of the Locus of Control of Behavior Scale (Rotter, 1966)
• Measurement of heart-rate during the initial VR trial (Empatica E4 wristband)
The VR platform (Oculus)
The current study makes use of a relatively low-cost system that is being tested with AWS. The research team created an environment where AWS could visit and introduce themselves to a large classroom audience using Unity 3D engine running on Oculus VR sysytem.
Procedure: Home Practice
• Participant and family takes the VR system home
• Practice once a day for at least 5 days a week for 2 weeks
• Participants given specific instructions to assist with setting up the VR simulation independently and what to do if “problems arise”
Procedure: Post-test
• Calculation of %SS while using the VR simulations
• Completion of the Stuttering Severity Instrument – 4 (SSI-4) (Riley, 2009)
• Completion of the Overall Assessment of the Speaker’s Assessment of Stuttering (OASES; Yaruss and Quesal (2008)
• Completion of the Locus of Control of Behavior Scale (Rotter, 1966)
• Measurement of heart-rate during the initial VR trial
• Completion of a short semi-structured interview related to their lived experiences using the VR simulation and how it impacted their stuttering and feelings
• Measurement of heart-rate during the final VR trial
• Completion of the Presence Questionairre
Data Analysis
• Descriptive statistics were collected for all quantitative measures
• SSI-4
• OASES
• Locus of Control Behavior Scale
• %SS
• Mean heart-rate
• Presence Questionnaire (Witmer & Singer, 1998)
• Pre-post measurement comparisons using paired samples t-tests and Wilcoxon paired sample tests (small n at this point)
• Thematic analysis of the semi-structure interviews will be conducted to analyze the interview data
Key Findings
• %SS went down for 3 of 4 participants when using VR for 2 weeks (for those who decreased %SS, it went down by 3.98%)
• Heart rate decreased in all 4; average HR change was 23.2
• Presence Questionnaire indicated reality (Norms from Moyenne = 104.39; Our data = 100.667)
• LCB dropped in 3 of 4; the average drop was 10.5
• All 4 dropped a small amount on OASES; average of 0.667
• SSI score was inconclusive: 2 went down; 1 went up; 1 stayed the same
Semi-Structured Interview Thematic Analysis
• Three major themes and two subthemes
• Fun
• Realistic
• Good Speech/ Practice
• Improved Speech
• More Confidence
Examples of Theme “Fun”
• Participant MM, line 42: “Because it was very, it was very fun. Very fun and exciting. I'm trying to be as really. Yeah.”
• Participant CA, line 2: “It was fun”
Examples of Theme “Realistic”
• Participant JL, line 36: “Oh because it's basically real life and it's *unintelligible*”
• Participant MM, line 50: “It looked pretty cool. I really liked it.” (in response to a follow-up question about reality)
Examples of Theme “Good Speech/ Practice”
1. Improved Speech
• Participant KL, line 20: “So on average, I would stutter like two out of every six times. I think it might increase if I don't use it to three or four times.”
• Participant NO, line 36: “Um like I didn't really stutter a lot. So, I haven't been stuttering a lot since I've finished it.”
2. More Confidence
• Participant MM, line 28: “It gave me more it it. So, I went I went I performed in front of a class for two weeks and I was pretty. I was pretty confident gives you confidence.”
• Participant KL, line 22: “Good. It was mostly just the first like two times I started that I did it…..then I was more confident”
Discussion for RQ1
What is the impact on stuttering skills following a two week at-home trial program using VR simulations?
• Significant decrease in stuttering in 3 of the 4 participants, as high as 4.8%
• Al-Nafjan (2021) also showed that 2 of their 3 participants exhibited a significant improvement when using VR
• Brundage (2006) study determined that their VR simulation significantly affected stuttered syllables
• their comparison was how two types of interview scenarios could exacerbate stuttered syllables
• The current study was not completed in a lab, but with devices that could be taken home
• Our study focused on the effects of continuous practice of VR, illuminating the effects of VR in a realistic therapeutic framework
• Improve devices utility & more appealing as a clinical tool
Discussion for RQ2
What is the impact on affective and cognitive feelings following an at-home trial program using VR simulations?
• Measured heart rate and determined an average heart rate change of 23.2
• Al-Nafjan (2021) study focused on effectiveness of using a VR environment on speech tasks and did not include affective measures
• Brundage (2006) examined VR effects on speaking confidence and apprehension in relation to stuttering severity
• Suggested that future studies should include physiological measures
• Found significant changes in the LCB
• No significant changes found with the OASES or SSI
Discussion for RQ3
What are the lived experiences of the PWS following an at-home trial program using VR simulations?
• Presence Questionnaire (Witmer & Singer, 1998) indicated that our VR simulations were “immersive”
• Brundage (2006) had similar findings; the Presence Questionnaire scores indicated that the VR interview scenario was immersive for all participants
• Al-Nafjan (2021) post-test interviews had comparable reports
• Our study further analyzed for other themes as well, which helps explain the underlying experience for our VR simulation
• Participants felt that the experience was fun and helpful and this might increase compliance and efficacy for VR as a therapeutic intervention
Limitations
• We were not able to account for the participants fidelity to the program during those two weeks, other than what they and their parents self-reported
• future studies should implement ways to track participants
• Only four participants have completed the study so far
• Increasing the number of participants
• Use of inferential statistics
• Length of the study was two weeks
• Increase the length of the study and longer-term follow-up
• Track over time
• Use of varied VR simulations in different settings with varying difficulty
Clinical Implications
• VR can be used as therapeutic practice, specifically for individuals who must commute long distances to therapy
• Individuals who are having difficulty utilizing their fluency techniques outside of the clinic could benefit from a virtual reality environment
• VR can control for extraneous, possibly damaging, variables that are not manageable in real-life
• Evidence shows that the VR experience decreased anxiety by measures of heart-rate and self-reports
Research Implications
• VR simulations helped PWS in almost every aspect of their stuttering (findings justify further study using this technology)
• VR has been used in many situations, such as flying airplanes, completing surgeries, teaching skills in a classroom (one of the first VR studies used with PWS)
• First study that used adolescents that stutter
• First that allowed participants to practice at home
• First to measure heart rate to support affective and cognitive gains
Selected References
American Speech-Language-Hearing Association. (n.d.). Stuttering. American Speech-Language-Hearing Association. Retrieved July 29, 2022, from https://www.asha.org/public/speech/disorders/stuttering/
Al-Nafjan, A., Alghamdi, N., & Almudhi, A. (2021). Virtual Reality Technology and Speech Analysis for People Who Stutter. EMITTER International Journal of Engineering Technology, 9(2), 326-338.
Brundage, S. B., & Graap, K. (2004). Virtual reality: An exciting new tool to enhance stuttering treatment. Perspectives on Fluency and Fluency Disorders, 14(2), 4-9. Brundage, S. B., Graap, K., Gibbons, K. F., Ferrer, M., & Brooks, J. (2006). Frequency of stuttering during challenging and supportive virtual reality job
interviews. Journal of fluency disorders, 31(4), 325-339.
Craig, A., Hancock, K., Tran, Y., Craig, M., & Peters, K. (2002). Epidemiology of stuttering in the community across the entire life span. Journal of Speech, Language,
and Hearing Research, 45(6), 1097–1105.
Everard, R. A., & Howell, P. (2018). We have a voice: Exploring participants' experiences of stuttering modification therapy. American Journal of Speech-Language
Pathology, 27(3S), 1273-1286.
Riley, & Bakker, K. (2009). SSI-4 : Stuttering severity instrument (4th ed.). Pro-Ed.
Rotter, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs: General and Applied, 80(1), 1– 28. https://doi.org/10.1037/h0092976
Tichenor, S. E., & Yaruss, J. S. (2019). Stuttering as defined by adults who stutter. Journal of Speech, Language, and Hearing Research, 62(12), 4356-4369. Yaruss, J. S., & Quesal, R. W. (2008). OASES: Overall assessment of the speaker's experience of stuttering : manual. Minneapolis, Minn: Pearson.