„Неофит Рилски“, Благоевград, Р. Бугарија MULTIDIMETIONAL OUTCOME AND LONG-TERM EVALUATION OF NON-AVOIDANCE STUTTERUNG THERAPY Evaluation with International Classification of Functioning, Disability, and Health (ICF)

Интернационалната класификација на функционирањето, попреченоста и здравјето (ICF, WHO, 2001) е конструктивна рамка за квалитетно дијагностицирање и терапија во логопедијата (терапија на говорот). Истражувањето прави обид за воведување на овој стандард во логопедската практика и за мерење на квалитетот на животот на лицата со нарушување на флуентноста на говорот, на пример, пелтечење. Квалитетот на животот е модерна мултидимензионална рамка што ги опфаќа здравствено-медицинските, психолошките, социјалните и економските фактори. Доброто ниво на комуникација и стабилизираната флуентност имаат големо значење во подобрување на квалитетот на животот на лицата кои пелтечат. Целта на истражувањето беше да се прикаже модел на дијагностицирање, третман и евалуација на ефикасноста на приложениот тераписки метод кај возрасни кои пелтечат. International Classification of Functioning, Disability, and Health (ICF, WHO, 2001) is a constructive framework for quality assessment and treatment in Logopedics (Speech Language Therapy). The current research study makes an attempt to introduce this standard into logopedical practice and applied research to measure the quality of life of persons with fluency disorders, such as stuttering. The quality of life is a modern multidimensional construct that covers health-medical, psychological, social and economic factors. Good level of communication and stabilized fluency is of key importance to improve the quality of life of persons who stutter. The purpose of the study was to show a model of assessment, treatment and evaluation of the efficacy of the non-avoidance approach in adult stuttering therapy.

International Classification of Functioning, Disability, and Health (ICF, WHO, 2001) is a constructive framework for quality assessment and treatment in Logopedics (Speech Language Therapy).The current research study makes an attempt to introduce this standard into logopedical practice and applied research to measure the quality of life of persons with fluency disorders, such as stuttering.The quality of life is a modern multidimensional construct that covers health-medical, psychological, social and economic factors.Good level of communication and stabilized fluency is of key importance to improve the quality of life of persons who stutter.
The purpose of the study was to show a model of assessment, treatment and evaluation of the efficacy of the non-avoidance approach in adult stuttering therapy.
stuttering behaviors), (iii) personal factors and affective, behavior and cognitive reactions, (iv) environmental factors, (v) activity limitations and participation restrictions.Unfortunately, in Bulgaria there are no research and science-based measurements of speech and language treatment services with the use of the ICF model.The National Scientific Fund of Bulgaria (the NSF) has funded only one highly successful research project in the professional field of Public Health and Logopedics (2009-2012, contract number DTK 02/33).It was about Evidence-Based Practice in Fluency and Voice Disorders, directed by D. Georgieva, South-West University "Neofit Rilski".The outcomes of intensive speech therapy with people of all ages who stutter were published in peer reviewed international journals (3,4,5).Medical treatment, health communication, social and psychological services for people who stutter were applied to enhance the quality of life of clients from the Southwestern region of Bulgaria, which include the capital, Sofia.A long term goal of the study was to encourage the development of health tourism in the area, which is defined as a region of health in a number of projects under the Sixth and Seventh EU Framework Program.The stuttering outcome is a change in the client's current and future fluency status that can be attributed to antecedent health care (6).Outcomes refer to the effects of therapy, programs or policies in individuals or population.Outcomes may also be defined as changes in status attributed to a specific intervention or therapy.Within the proposed study below, an attempt is made aiming to introduce this ICF standard practice in Logopedic and Logopedic applied research for measuring the multiple outcomes in individuals with stuttering.(7).Бугарскиот систем за здравствена заштита не опфаќа логопедски третман за адолесценти и возрасни лица кои пелтечат.Во бројни меѓународни публикации и на конгреси на светско ниво, земјата е критикувана поради тоа што не им нуди логопедски услуги на лицата кои пелтечат (8)(9)(10)(11).Критиката упатена кон бугарската практика ги наметна европските стандарди за обезбедување на квалитетни логопедски услуги и развој на инструменти за мерење на квалитетот на животот на лицата со нарушувања во комуникацијата како целина.Бугарија успешно учествуваше во мрежниот проект на 65 европски универзитети, финансиран од Европскиот социјален фонд, под наслов "Мрежа за синхронизирање на стандардите и квалитетот на образовните програми за логопедите во Европа" 2010-2013, број на проектот 177 075-LLp-1-2010-1-FR-EARSMUSENWA (12) и му беше доделен грант во 2013 година "Практика базирана на

Relevance of scientific problems in Bulgaria and Europe
The EU Statistics Classification was accepted in Bulgaria in 2008.According to the EU Statistics Classification of 1999 and its methodological handbook ISCED 97 Logopedics (Speech Language Therapy) is considered a health profession and is located in professional direction 726 physiotherapy and rehabilitation.As a new member of the EU, Bulgaria undoubtedly adheres to these rules.In July 2009, the Speech Language Therapy program at South-West University in Blagoevgrad, Bulgaria successfully completed the official procedure of accreditation and evaluation as part of the health sciences professions.This act created the required conditions for conducting significant research in the field of Speech Language Pathology following the ICF model.Some statistical data on communication, speech and language disorders in Bulgaria: 2.5% of the country's total population, or 150 000 people, are affected by stuttering or other dysfluency type.4% of school aged children suffer from stuttering (7).The Bulgarian healthcare system offers no logopedic treatment for adolescents and adults who stutter.In a number of international publications and world congresses, the country is being criticized for not offering speech therapy service to adult persons who stutter (8)(9)(10)(11) in Stuttering and Voice Disorders" -the only research project in the field of speech therapy in Bulgaria won by the author of the present article (13).In the frame of those projects the new paradigm "evidence-based practice" in accordance with the ICF model was strongly recommended.The new concept for the application of the ICF classification in the field of communication disorders (in the context of this current topic: stuttering) is not known by Bulgarian speech language therapists.It is fundamental with respect to speech language pathology science and therapy in some countries of the European Union, the USA, Australia and Canada.This new paradigm refers to an approach in which the current, highly qualitative research practiceс attempt to provide data not only about the clients' satisfaction from the comprehensive speech service, but also about the clients' quality of life.In Bulgaria, in general, no systematic publications on the problem have been published, even though in the European (CPLOL) and international (IALP) speech language pathology organizations this model is specified as a standard.The medical model of stuttering seeks to reveal the causes and to provide proper therapy for the persons with this communication disorder.Published scientific studies in the U.S., Canada, Australia; England draw attention to the diagnosis of the external, visible characteristics of stuttering and puts minor emphasis on the evaluation of the experience of the person who stutters as a speaker (14)(15)(16)(17).The social, psychological and logopedical model focuses on the inclusion of the person who stutters in the society and also emphasizes the quality of his/her life.The review of the Bulgarian literature indicated a lack of knowledge of the ICF model in the country (see Table 1).This fact makes the scientists and especially speech language therapists recognize the need for broad-based implementation of evidencebased assessment and therapy for this complex communication disorder.

Basic considerations
The design of the therapy program was elaborated by Steen Fibiger and was based on the following considerations:  Van Riper's stuttering modification approach was applied. The team of speech therapists consider motivation as a major element in the adult stuttering therapy (AST).A lack of motivation was observed for one adult.The possible explanation was a reflection of discouragement because of the 'poor" results of the precedent treatment. WASSP Summary Profile was applied as a way of measuring change in feelings, thoughts and behaviors and planning future management (35,36).This profile aims to record how the person who stutters perceives his or her stuttering at the beginning and the end of a block of speech and language therapy.WASSP is an indicator for improvement in the quality of life after the therapy period. The AST requires involvement of four speech language therapists. The official training language was Bulgarian, but all of the participants were fluent in English.Specific therapy methods for assessment (SSI-3) and treatment of stuttering in adults, as well as measurement of the effectiveness of Logopedic interventions (46) were also conducted.The application of voice acoustic analysis of the voice of adults who stutter has also been planned using computerized speech laboratory (CSL) and specific softwares as RTP (Real Time Pitch), and EGG (electroglottography), (47,48).To take these measures in voice disorders is not obligatory but advisable.It is intended to use these various tools in the field of Public Health -Logopedics to achieve ната цел (за детален опис, погледни ја табелата 2, долу).
fluent speech (for a detailed description see

Specific research activities
The main goal of the present study was to assess therapy outcomes using a variety of stuttering measurements based on Van Riper's intensive therapy approach.Second research was conducted to specify any changes that are adopted in different speech situations (in the stabilization phase), and to demonstrate that changes are maintained after the therapy (1, 2, and 3 years after the treatment).Measurement for adults includes determination of index of dysfluencies (ID) -the number of stuttering events divided by the number of syllables, and duration of dysfluences (DDs)in seconds, for the three longest stuttering events.Specific stuttering measurements: Application of SSI -3 developed by Riley ( 46) -(Table 2 and Table 3).Reliability of measures: After the IT and each of the stabilization phase sessions, a five-minute video-recorded spontaneous speech sample was obtained from each of the participants.Each speaking sample contains at least 300-400 syllables to ensure reliable results.External independent evaluation was provided by an independent clinician.He reported "measurement agreement" 95%.Validity: predictive validity (criterion validity) is a gold standard because it refers to the ability to predict future measures.At the end of the intensive adult stutterers' therapy we could accurately predict whether clients would maintain their gains.

Evidence-based practice:
A good clinical practice should and must be based on evidence.The clients'WASSP profiles were analysed individually.
The study offers a quantitative measure not necessarily requiring normative comparisons regarding 2011 and 2012 -the so-called post treatment period.Statistics methods: The data obtained were calculated using the Wilcoxon signed-ranks test for hypotheses testing.At the beginning of the treatment DD was 3.8 seconds and immediately after IT this parameter reduced to 0.8 sec.Some changes in DD were observed over the first and second months after the IT.For this client it was difficult to maintain some of the new speech modification techniques like pull-out and cancellation.The preparatory set technique was applied successfully and stabilized by the client after 6 months of training after the IT.The 0.5sec DD increased slightly 3 years after the IT.

Промени во говорната флуентност Changes in speech fluency
Embarrassment, fears and anger were typically presented after the student exam session.They characterized the so-called educational disadvantages of client 4 and they are related to his poor educational achievements in that period. Before IT and 1 year after IT (Z -3.408; p < 0.001)  Before IT and 2 years after IT (Z -3.409; p < 0.001)  Before IT and 3 years after IT (Z -3.408; p < 0.001).Sustained reduction in DDs was achieved (p < 0.001).There was a significant reduction in the average duration of fluency disruptions.There was a statistically significant reduction of DDs:  After IT and 1 year after IT: (Z -0.692; p < 0.489)  After IT and 2 years after IT: (Z -0.684; p < 0.494)  After IT and 3 years after IT: (Z -1.329; p < 0.184).This means that he manifested fluent speech.

Слика 2. Времетраење на нефлуентностите во секунди, на почетокот спроти крајот на интензивната терапија, па по една, две и три години по интензивната терапија за сите учесници (n=15), (5, 13)
There was a period of instability and variation of the DI curve where the participant reverted to dysfluent speech (movements between 0.3% and a rapid increasing to 11.5%).From the client's files it was possible to show that he reported strong frustration between the 2 nd and 4 th months after the IT, related to associated health problems.Subsequently, the curve demonstrated strong maintenance of the fluent speech behavior and stabilization of fluency 3 years after the IT.To summarize, the client needed a prolonged period of time to consolidate the newly established speech behavior when the totally new speech techniques were applied in this sensitive period.The overall pattern showed that in order to stabilize the new stuttering behaviors acquired during the IT, continued treatment and psychological and social support for a long period are needed.Such long term support allows stabilization to continue and helps manage relapses to the old stuttering behaviors.Significant changes regarding reduction of disfluency index were found before and after intensive therapy (Z -3.408; p < 0.001).DI before and after the IT show the next results:  Before and after the 1 st year (Z -3.411; p < 0.001)  Before and after the 2 nd year (Z -3.408; p < 0.001)  Before and after the 3 rd year month (Z -3.408; р < 0.001).DI after the IT and after 1, 2, 3 years post therapy show:  After IT and after the 1 st year (Z -3.068; p < 0.002)  After IT and after the 2 nd year (Z -3.408; p < 0.001)  After IT and after the 3 rd year month (Z -3.202; р < 0.001).

WASSP Group results
The set of WASSP subscales results revealed considerable positive changes in response to participation in the therapy course for the majority of the participants.It includes behaviors, thoughts, feelings, avoidance and disadvantage scales.They reported a visible change of progress in all five subscales of the WASSP.The majority of clients were strongly motivated and reduced their degree of stuttering from the beginning of the intensive therapy.The rest of the WASSP parameters changed in positive way.

Заклучок Conclusion
Позитивните промени во говорната флуентност пред и по интензивната терапија и во периодот што следува (една, две и три години по интензивната терапија), беа постигнати во однос на два суштински параметри: (1) времетраење на нефлуентностите, и (2) индекс на нефлуентноста (5,13).The positive changes in speech fluency before and after the intensive therapy and in the follow up period (one, two and three years after the intensive therapy) were obtained regarding the two essential parameters: (i) duration of dysfluencies, and (ii) index of dysfluency (5,13).Improvement in stuttering duration was observed immediately upon completing the intensive therapy.This was reflected in a statistically significant reduction in the number of stuttered utterances per minute.In the period of nine months stabilization phase, one year, two years and three years after the therapy these positive changes were maintained.
avoidance approach is a classic example of stuttering modification approach to stuttering therapy, it is only one variant of many stuttering modification therapies.We do not know whether these results can be generalized to other stuttering modification approaches.Perhaps simply participating in the present type of group stuttering intervention may be sufficient to bring about the positive changes of the type and magnitude that we observed (5,13).
Results from this study showed that International Classification of Functioning, Disability, and Health are a beneficial framework for quality assessment and therapy in logopedics regarding stuttering.This study introduced for the first time in Bulgarian logopedical practice stuttering modification approach and represents a good example of therapy outcomes evidence-based measurement.

Слика 1 . 4 Figure 1 .
Figure 1.Duration of dysfluencies in seconds at the beginning versus end of the intensive treatment, and one, two and three years after the intensive treatment for subject 4

Figure 2 .
Figure 2. Duration of dysfluencies in seconds at the beginning versus end of the intensive treatment, and one, two and three years after the intensive treatment for all participants (n=15),(5,13)

Слика 3 . 4 Figure 3 .
Figure 3. Dysfluency index in % at the beginning versus end of the intensive treatment, and one, two and three years after the intensive treatment for subject 4

Figure 4 .
Figure 4. Dysfluency Index at the beginning versus end of the intensive therapy and one, two and three years after the intensive therapy for all participants (n=15),(5,13)

Table 2 .
ICF components, providing a detailed stuttering description in the current research

Assessment of the Speaker's Experience of Stuttering
-Yaruss and Quesal, (2, 54) -in process of translation and adaptation for Bulgarian conditions