EVIDENCE BASED PRACTICE

Tightening up

on relaxation
Do you use relaxation methods in your work? How do you decide if a client would benefit and what particular approaches would suit? While most evaluation studies of relaxation in speech and language therapy report significant improvements, Marcus Stck, Thomas Rigotti and Ulrike Ldtke are concerned by their lack of scientific rigour.
hile the use of relaxation techniques in speech and language therapy is widespread, this utilisation, as well as belief in their effectiveness, often seems to be based on everyday theoretical presumptions rather than on empirical evidence - a situation that has a detrimental effect on the scientific reputation of relaxation methods. In this literature review of relaxation methods for speech, language and communication disorders over the last 30 years, we try to answer the questions: 1) Which speech and language therapy-related disorder patterns have been examined most frequently for their response to relaxation? 2) What relaxation methods have been investigated? Which methods have been combined? 3) What methodologies have the studies been based on? 4) How effective is the application of relaxation methods in speech and language therapy? We took great effort in acquiring, as completely as possible, all papers relating to this subject in the form of monographs, papers in anthologies, review articles and dissertations. Research was by title and / or keywords in the medline, psyndex and psyclit databases from 1972 to 2002. The initial 111 papers were reduced to 80 in the course of the selection process. By applying liberal criteria, we gave priority to thematic relevance over methodological quality. We excluded only those papers that did not study relaxation methods as applied speech and language therapy techniques, such as purely theoretical papers, metastudies on partial aspects, and papers on educational and training concepts. We coded the studies by country of origin, date of publication, speech and language therapy pattern examined, relaxation method applied and research method used. 1) Which speech and language therapy-related disorder patterns have been examined most frequently for their response to relaxation? Here we had the problem of bringing a highly divergent multinational terminology into line. To reflect the current situation in German-speaking countries, coding was effected according to the disorder pattern classification described in the manual of speech therapy pedagogy and speech therapy (Grohnfeldt, 2001), while only dyslexia and psychogenic cough habit used in the AngloAmerican world have been included in terms of terminology and / or context.

Figure 1 shows the percentage analysis. It is striking that investigations in stuttering carried out between 1972 and 2002 account for 56.5 per cent of all studies considered, followed by dysphonia and language development retardation at 10.6 per cent each, then dyslexia at 8 per cent. The first two are not surprising, since stuttering and voice defects can be regarded as classical psychoreactive disorders, attributed to mental-emotional processes, which causally justify the application of relaxation methods. Centralised speech disorders such as aphasia and apraxia, as well as organic disorders such as laryngectomy, are marginal fields amongst relaxation research activities, but the central disorder groups of language development retardation and dyslexia have to be analysed in more detail. Firstly, we assume there is an interdisciplinary methodological hypothesis that children respond very well to relaxation methods. Secondly, it is noticeable that a changed understanding of the consequences of speech, language and communication disorders in children has contributed to an upswing in research since 1987.
Figure 1 Frequency of studies by speech defect patterns (LDR = Language Development Retardation)

IF YOU ARE INTERESTED IN CARRYING OUT A LITERATURE REVIEW COMBINING TREATMENT METHODS A EUROPEAN PERSPECTIVE ON SPEECH AND LANGUAGE THERAPY
Marcus Stck

Dyslexia 8% Dysphonia 11% Laryngectomy 2% Mutism 1% Psychogenic Cough Habit 1%

Apraxia 2%

Aphasia 6%

Stutter 57%

LDR 11%

Speech Anxiety 1%

Thomas Rigotti

Ulrike Ldtke

2) What relaxation methods have been investigated? Which methods have been combined? We classified the relaxation methods according to Vaitl & Petermann (2000): Relaxation (unspecific) - no specific technique is named and there is no detailed description Relaxation (specific) - we created this as a generic term to cover specifically named techniques, for example cinesiology, which occurred only once but were described in detail Autosuggestion (Schultz, 1973) Progressive muscle relaxation (Jacobson, 1929)

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SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

EVIDENCE BASED PRACTICE

Muscle relaxation oriented towards behaviour therapy as a comprehensive term for techniques based on systematic desensibilisation (Wolpe, 1958) and consequent modifications, for example self-control methods (Wolpe & Lazarus, 1966) Yoga relaxation as a generic term for different Yoga techniques, inducing the psychophysiological relaxation reaction in different ways, such as through body postures (asana) or breathing exercises (pranayama) Massage as a generic term for different massage techniques Biofeedback as a generic term for EEG feedback, EMG feedback, vasomotoric feedback and cardiovascular feedback Imagination as a generic term for classical behaviourtherapy imagination techniques, such as rationalemotive therapy (Ellis & Grieger, 1977), imagination control technique such as Guided Imaginal Coping (Watkins et al, 1988) and emotional imagination including Emotive Imagination (Lang, 1977) as well as independent approaches, such as Guided Affective Imagery (formerly Catathyme picture experiencing - Leuner, 1970) or the Simonton Method (Simonton et al, 1980) Meditation as a generic term for several techniques of specific meditative systems such as Zen-buddhist meditation, Yoga meditation or Transcendental meditation. The main difficulty was the intermingling of different levels: autosuggestion and progressive muscle relaxation are specifically defined, widespread, classical relaxation methods; while behaviour-therapy oriented muscle relaxation, Yoga relaxation, massage, biofeedback, imagination and meditation are generic terms for entire philosophies or systems of relaxation techniques.
Figure 2 Relaxation methods that have been investigated in speech and language therapy

In a very large group of studies (14.1 per cent, n =12), several relaxation methods have been considered in a combination. In 6 out of these 12 studies, biofeedback was combined with other methods, all without detailed specification and once with the addition of meditation. Biofeedback was examined only 6 times in the 80 studies grouped together but there is not a single study which looked at its application in a completely isolated manner. Imagination was considered a total of five times in the 12 combining studies. Progressive muscle relaxation was examined in combination with other methods only twice: once with behaviouroriented muscle relaxation, once with imagination. In total, progressive muscle relaxation was looked at five times within the 80 studies and three times as an isolated method. 3) What methodologies have the studies been based on? For this question, we coded the studies on the basis of the research methods explicitly mentioned in the keywords or in the abstract, which were specified according to international databases as: Empirical Study Empirical Study & Follow-up Study Clinical Case Report Experience Report Review combinations of several methods. This showed that the application of relaxation methods in the context of speech and language therapy had, in most cases, been investigated by empirical studies or experience reports: empirical studies alone 23 times (27 per cent), 9 times in combination with follow-up inquiries (10.6 per

cent), and experience reports alone 26 times (30.6 per cent). Clinical case reports have been used alone 16 times (18.8 per cent) and once (1.2 per cent) in combination with a follow-up study. Reviews alone have been used in 7 cases (8.2 per cent), 2 times (2.4 per cent) in combination with clinical case reports, and once (1.2 per cent) in combination with an experience report. Table 1 allows us to estimate whether certain disorder patterns are associated with particular methodological approaches (quantitative-empirical versus non-statistical), as it shows the percentage ratios between these two approach categories. The effectiveness of relaxation methods to treat stuttering has been particularly well examined, with a wide range of methods employed. However, while experience reports have been used 18 times (42.8 per cent), clinical case reports have only been given once (2.4 per cent). Apraxia - also in combination with aphasia - has not yet been covered by an empirical study, nor have mutism, laryngectomy, psychogenic cough habit and speech anxiety. Non-statistical approaches clearly prevail on all the disorder patterns. Only stuttering and language development retardation do not show too large an imbalance versus empirical approaches. 4. How effective is the application of relaxation methods in speech and language therapy? To gain a first insight here, we examined the empirical studies carried out for the individual disorder patterns as an isolated group, and filtered out statements on their effectiveness given in the abstracts. We did not take apraxia, laryngectomy, mutism, psychogenic cough habit and speech anxiety

Table 1 Ratios between the approach categories per disorder pattern

Several methods combined Biofeedback 14% 0% Massage 1% Yoga relaxation 1% Meditation 4% Progressive muscle relaxation 4% Relaxation (specific) 4% Behavioural or muscle relaxation 8%

Disorder pattern Aphasia Apraxia Aphasia and Apraxia Dyslexia

Investigation method applied Empirical Study Clinical Case Report Review Review Empirical Study Clinical Case Report Experience Report Empirical Study Clinical Case Report Experience Report Combined: Clinical Case Report & Follow-up Review Clinical Case Report Clinical Case Report Combined: Clinical Case Report & Review Empirical Study Clinical Case Report Experience Report Experience Report Empirical Study Combined: Empirical Study & Follow-up Study Clinical Case Report Experience Report Combined: Experience Report & Review Review Combined: Review & Clinical Case Report Review

Relaxation (unspecific) 27%

Number of studies 2 3 1 1 2 4 1 3 2 2 1 1 1 1 1 4 1 4 1 9 9 1 18 1 4 1 1

Ratio in per cent 40.0 60.0 28.6 / 71.4

Dysphonia

33.3 / 66.7

Laryngectomy

Autosuggestion 13%

Imagination 24%

Mutism Psychogenic Habit Cough Language development retardation Speech anxiety Stuttering

What is generally worrying in figure 2 is the high theory deficit, inaccuracy and lack of detail in research methods; at 27 per cent, relaxation (unspecific) represents the largest group of studies. The second largest group imagination is also a collective group, since the abstracts almost exclusively indicate the generic term instead of well-specified imaginative techniques. The third largest group, several methods, is also very heterogeneous, with a trend towards combining imagination with any other possible method, without taking into account theoretical compatibility. Amongst the specific methods, autosuggestion constitutes the only exemplary exception (12.9 per cent).

44.4 / 55.6 -

42.9 / 57.1

Stuttering & Speech anxiety Stuttering & Dyslexia

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

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EVIDENCE BASED PRACTICE

Starting Point for health visitors

I CAN, the charity that helps children communicate, has developed a Starting Point on speech, language and communication needs for health visitors. The online information service is a dedicated section of the Talking Point website, and follows consultation with health visitors about the information they need to identify and support children with speech, language and communication difficulties and their parents. Health visitors are already the largest single referrers of children to community speech and language therapy services, and their early intervention can prove crucial to the outcome. They said they would most value information on key stages of childrens speech and language development and the influencing factors, different types of language difficulty, practical advice and strategies for language development to share with families and information and advice sheets to give out. In addition the site, funded by the Department of Health, gives them the opportunity to ask questions of experts, to browse abstracts of successful multidisciplinary working and to access training and conference information. www.talkingpoint.org.uk/startingpoint

news extra

into account given the lack of empirical studies. As table 2 shows, the result is a very heterogeneous picture, which cannot be described by numbers, but only by citation:
Table 2 Details on the effectiveness of relaxation methods in empirical studies

Disorder pattern Aphasia Dyslexia Dysphonia

Number Number of of empirical test studies persons 2 23 6 2 3 ? 60 8 1 16 8 10 2 ? 1 1 5 40 ? 9 24 57 1 4 61 8 8 10 6 10 25 89

Details on effectiveness significant not significant significant significant findings in 7 condition unchanged high significance it may enhance might benefit can be enhanced ? highly significant significant significant 77% improvement successful significant significant 74% improvement considerable improvements changes ? 5 considerably improved significant 90% improvement symptom reduction improvement effective multilateral effect

Language development retardation Stuttering

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Their effectiveness in the treatment of different communication disorder patterns has not been proven on a scientific level; rather, their application in the context of speech and language therapy is based on everyday hypotheses. This gap urgently needs to be filled by adequate research designs: Relaxation methods should be examined specifically f o r their effect on non-psychoreactive disorder patterns (organic, central and development-related phenomena) Research has to focus on highly accurate, specific methods without watering-down and inexact mixing Generally, empirical studies have to be supported by statistical methods Such statistical methods should be applied to all disorder patterns, not only stuttering and language development retardation Meta-analyses should be performed to come to general conclusions concerning the effectiveness of relaxation methods in the treatment of speech, language and communication disorders. Taking into account all methodological limitations, our results point towards the usefulness of integrating relaxation methods. We would therefore like to encourage not only scientists but also practitioners to evaluate the application of relaxation methods in speech and language therapy. We hope our review will lead to more strictly designed research that will determine the best way of using relaxation methods to benefit people with language, speech and communication needs. Marcus Stck, PhD (e-mail stueck@rz.uni-leipzig.de) and Thomas Rigotti, MSc (e-mail rigotti@uni-leipzig.de) are Psychologists based at the Institute of Applied Psychology, University of Leipzig, Seeburgstr. 14-20, D04103 Leipzig. Ulrike Ldtke, PhD (e-mail uluedtke@uni-bremen.de) is a speech and language therapist based at Erziehungs- und Bildungswissenschaft, Department of Education Sciences, University of Bremen, Bibliothekstr. 1 - 28359 Bremen. References used for the literature review are available on the speechmag website www.speechmag.com.

Duty a big deal for disabled people

Public sector bodies, including health and education, will have a duty to promote disability equality in all aspects of their work from next year. Changes to the Disability Discrimination Act being introduced by the government will work in a similar way to the Race Relations Amendment Act. The Disability Rights Commission is consulting on a draft Code of Practice it has drawn up to support the amended legislation. Chairman of the Disability Rights Commission, Bert Massie, said, The Code of Practice will help people understand major changes to duties on the public sector. It is hard to overstate just how big a deal the new duty will be for disabled people. The three month consultation period ends on 21st April 2005 and the final Code will be available in December 2005. Versions of The Duty to Promote Disability Equality: Statutory Code of Practice are available from www.drc-gb.org or Helpline 08457 622 633. (Please specify England & Wales or Scotland.)

Although about two thirds of the studies designate effectiveness by terms such as significant or improved, the extreme heterogeneity and the lack of figures suggest that we cannot generalise statements about effectiveness. We need detailed methodological verification (research design, baseline, drop-out rate, parallelisation of groups) before a study can be designated empirical. This theory deficit is also reflected in the research methodology of the individual studies. It is alarming that experience reports, accounting for 31 per cent, constitute the largest methodological group (see table 1). Moreover, when the non-statistical experience reports, clinical case reports and abstract papers are grouped together and contrasted with the 27 per cent group of empirical studies - without taking into account the 15 per cent group of combined methods - they account for 58 per cent of the total. This general methodological imbalance shows that we need more emphasis on the application of statistical methods - and the positive trend from the studies on stuttering and language development retardation demonstrates this is possible. There is a huge research deficit in the application of relaxation methods in speech and language therapy.

References
Ellis, A. & Grieger, R. (Eds.) (1977) Handbook of RationalEmotive Therapy. New York: Springer Publishing Company. Grohnfeldt, M. (Ed.) (2001) Lehrbuch der Sprachheilpdagogik und Logopdie, Bd.2: Erscheinungsformen und Strungsbilder. Stuttgart: Kohlhammer. Jacobson, E. (1929) Progressive Relaxation. Chicago: University of Chicago Press. Lang, P.J. (1977) Imagery in therapy: An information processing analysis of fear. Behavior Therapy 8 (5): 862-886. Leuner, H. (1970) Katathymes Bilderleben. Stuttgart: Thieme. Schultz, I.H. (1973) Das Autogene Training. Stuttgart: Georg Thieme Verlag. Simonton, O.C., Mathews-Simonton, S. & Sparks, T.F. (1980) Psychological intervention in the treatment of cancer. Psychosomatics 21: 226-233. Vaitl, D. & Petermann, F. (Eds.) (2000) Handbuch der Entspannungsverfahren. Bd.1: Grundlagen und Methoden. Weinheim: Beltz. Watkins, P.L., Sturgis, E.T. & Clum, G.A. (1988) Guided imaginal coping: An integrative treatment for panic disorder. Journal of Behaviour Therapy and Experimental Psychiatry 19 (2): 147-155. Wolpe, J. (1958) Psychotherapy by reciprocal inhibition. Oxford, England: Stanford University Press. Wolpe, J. & Lazarus, A.A. (1966) Behavior therapy technique. New York: Pergamon Press.

DO I APPRECIATE THE RELATIVE MERITS OF DIFFERENT LEVELS OF EVIDENCE? DO I GET THE MOST OUT OF LITERATURE SEARCHES BY LOOKING FOR THEME FIRST, METHODOLOGY SECOND? DO I ALLOW THE LACK OF INTERNATIONAL AGREEMENT ON DESCRIPTIVE TERMINOLOGY TO LIMIT MY ACCESS TO RESEARCH STUDIES?

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