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PubMed2005

Randomised controlled trial of the Lidcombe programme of early stuttering intervention.

OBJECTIVES: To evaluate the efficacy of the Lidcombe programme of early stuttering intervention by comparison to a control group. DESIGN: A pragmatic, open plan, parallel group, randomised controlled trial with blinded outcome assessment. SETTING: Two public speech clinics in New Zealand. PARTICIPANTS: Stuttering preschool children who presented to the speech clinics for treatment. Inclusion criteria were age 3-6 years and frequency of stuttering of at least 2% syllables stuttered. Exclusion criteria were onset of stuttering during the six months before recruitment and treatment for stuttering during the previous 12 months. 54 participants were randomised: 29 to the Lidcombe programme arm and 25 to the control arm. 12 of the participants were girls. INTERVENTION: Lidcombe programme of early stuttering intervention. MAIN OUTCOME MEASURES: Frequency of stuttering was measured as the proportion of syllables stuttered, from audiotaped recordings of participants' conversational speech outside the clinic. Parents in both arms of the trial collected speech samples in three different speaking situations before randomisation and at three, six, and nine months after randomisation. RESULTS: Analysis showed a highly significant difference (P = 0.003) at nine months after randomisation. The mean proportion of syllables stuttered at nine months after randomisation was 1.5% (SD 1.4) for the treatment arm and 3.9% (SD 3.5) for the control arm, giving an effect size of 2.3% of syllables stuttered (95% confidence interval 0.8 to 3.9). This effect size was more than double the minimum clinically worthwhile difference specified in the trial protocol. CONCLUSIONS: The results provide evidence from a randomised controlled trial to support early intervention for stuttering. The Lidcombe programme is an efficacious treatment for stuttering in children of preschool age.

Child↗
PubMedDate not supplied

Perceptual and acoustic evidence for reduced fluency in the vicinity of stuttering episodes.

A perceptual experiment and acoustic analyses were conducted to address the question whether stuttering occurs only at specific "moments" or whether it also affects the surrounding speech. Sections of stutterers' speech were extracted from clauses which were spoken completely fluently (control) or contained one stutter (experimental). In the experimental sections, only speech up to or following the stuttered word was employed. All sections were rated by independent groups of subjects for fluency, the nature of the excised stutter (repetition or prolongation), and the temporal position of the stutter relative to the fluent section that they heard (before or after). Two additional groups of listeners were asked to select from experimental-control pairs the section that had been drawn from near a stutter, and to indicate type and position of the stutter. Listeners could reliably judge which sections had been near a stutter and the type of that stutter, but not its position. Acoustic analyses showed that there were no differences in duration, rate, number of pauses, and average intensity between the experimental and control sections. However, there were significant differences in terms of the drop in intensity between the syllables in the respective sections. The perceptual identification of experimental versus control sections showed a significant relationship with this acoustic measure and with speech rate. The judgments about the type of stutter only correlated with drop in intensity. We conclude that stuttering episodes affect the intensity-time profile of the speech in their vicinity, and that listeners can use this acoustic information to infer the presence and type of the stutter.

Humans↗
PubMed1975

Dichotic ear preferences of stuttering children and adults.

39 stutterers and 39 normal speakers indicated their ear preferences for dichotically presented words and digits. A single response mode for both dichotic words and digits was selected to study speech perception. Stutterers showed significantly less of the normal right-ear preference for dichotic words and digits than non-stutterers. The proportion of stutterers who failed to demonstrate a right-ear preference for dichotic words was significantly greater than for non-stutterers. 18% of the stutterers and none of the non-stutterers showed reversed or a left-ear preference for dichotic digits. Although non-stuttering children and adults performed alike on the dichotic tasks, the right-ear dichotic-words scores of stuttering children were significantly smaller than those of adult stutterers. The results are related to an early notion that stuttering may be related to mixed dominance and recent evidence showing that large percentages of older stuttering children show spontaneous remission of stuttering.

Acoustic Stimulation↗
PubMed2001

[Value of acoustic speech analysis for prognostic assessment of stuttering in children. Partial results of a prospective longitudinal study].

UNLABELLED: PRESENT STATE OF KNOWLEDGE: There are currently no known acoustic parameters by which stuttering children can be appraised which will predict their subsequent speech fluency. AIM: To explain the significance of factors which perpetuate stuttering by using computer-based speech analysis of fluent speech for a 1 1/2 year period and to relate acoustic analysis with clinical measurements of stuttering. Special attention was given to motor-oral and/or linguistic deficits. METHOD AND RESULTS: A prospective study of 58 pre-school children who stutter. Correlations were sought between acoustic variables in the severity and course of the stuttering with the influence of motor-oral and linguistic disturbances. 19 age-matched, normal-speaking children served as controls. A subdivision of the study group into different subgroups with particular motor-oral and/or linguistic problems showed that children whose stuttering coincides with a delayed speech development have a distinctly better prognosis for early remission. In most of these children the stuttering remitted to such a degree as the deficits causing the stuttering could be reappraised, which means simultaneous improvement of the linguistic competence. CONCLUSION: It was apparent that remission rate was much higher in those children who showed linguistic disturbances at the same time with stuttering. Within the stuttering group, subgroups showed a few correlations in several acoustic parameters, but these could not, as yet, be shown to give any prognostic markers in the routine diagnosis of children who stutter. If a child shows any danger-signs of acquiring stuttering on a more permanent basis, a careful diagnosis is necessary in order to find the individually underlying factors before any therapeutical procedure.

Child↗
PubMed2006

Phonological skills and disfluency levels in preschool children who stutter.

UNLABELLED: The relation between stuttering and aspects of language, including phonology, has been investigated for many years. Whereas past literature reported that the incidence of phonological difficulties is higher for children who stutter when compared to normally fluent children, the suggestion of association between the two disorders also drew several critical evaluations. Nevertheless, only a limited amount of information exists concerning the manner and extent to which the speech sound errors exhibited by young children who stutter, close to stuttering onset, is related to the characteristics of their stuttering, such as its severity. Conversely, information is limited regarding the effects a child's phonological skills may have on his/her stuttering severity. The current study investigated the mutual relations between these two factors in 28 carefully selected preschool children near the onset of their stuttering. The children, 20 boys and 8 girls, ranged in age from 25 to 38 months, with a mean of 32.2 months. The phonological skills of two groups with different ratings of stuttering were compared. Similarly, the stuttering severities of two groups with different levels of phonological skills (minimal deviations-moderate deviations) were compared. No statistically significant differences were found for either of the two factors. Inspection of the data revealed interesting individual differences. LEARNING OUTCOMES: The reader will be able to list: (1) differences in the phonological skills of preschool children whose stuttering is severe as compared to children whose stuttering is mild and (2) differences in stuttering severity in preschool children with minimal phonological deviations as compared to children with moderate phonological deviations.

Articulation Disorders↗
PubMed2004

Linguistic stress, within-word position, and grammatical class in relation to early childhood stuttering.

UNLABELLED: The purpose of the present study was to investigate whether the link that has been established between stuttering and linguistic stress in adolescents and adults (the so-called stress effect) can also be observed in childhood stuttering. To account for confounding variables, both within-word position and grammatical class were measured, because these factors covary with linguistic stress. Speech samples of 22 preschool children (mean time of 9 months since onset of stuttering) were analyzed. The relative stress of each syllable was rated and syllables were categorized into long and short stressed, unstressed, and intermediately stressed syllables. Results showed that 97.8% of stuttering events occurred on first syllables of words and 76.5% on the first sound of syllables, that means a clear word-initial effect. Stuttering frequency on first syllables of function words was 16.9% and significantly higher than the frequency of stuttered first syllables of content words (11.5%). In function words short stressed syllables and intermediately stressed syllables were stuttered more often than unstressed syllables. The analysis for individual disfluency types revealed that, for function words, stuttering on short stressed syllables was associated with prolongations and syllable repetitions. However, in intermediately stressed syllables stuttering coincided most often with one-syllable word repetitions. This differentiation of the stress effect may suggest different causal mechanisms underlying these disfluency types. EDUCATIONAL OBJECTIVES: The reader will learn about and be able to: (1) describe how within-word position, grammatical class, and linguistic stress effect stuttering frequency in preschool children who stutter; (2) explain how the occurrence of individual disfluency types depends on linguistic stress; (3) discuss how patterns of adults and preschool children who stutter differ in regard to these aspects.

Child, Preschool↗
PubMed2004

The relationship between anxiety and stuttering: a multidimensional approach.

UNLABELLED: The relationship between anxiety and stuttering is equivocal from both clinical and empirical perspectives. This study examined the relationship within the framework of the multidimensional interaction model of anxiety that includes an approach to general anxiety in specific situations [J. Pers. Soc. Psychol. 60 (1991) 919]. Ninety-four males aged 18-43, half disfluent speakers and half fluent speakers completed two questionnaires: The Trait Anxiety Inventory [C.D. Spielberger, R.L. Gorsuch, R.E. Lushene, Manual for the State-Trait Anxiety Inventory (Self Evaluation Questionnaire), Consulting Psychologists Press, Palo Alto, CA, 1970] and the Speech Situation Checklist [G.J. Brutten, Neurolinguistic Approaches to Stuttering, Mouton, The Hague; G.J. Brutten, Stuttering: A Second Symposium, Harper and Row, New York, 1973; G.J. Brutten, P. Janssen, Proceedings 18th Congress of the International Association of Logopedics and Phoniatrists, Washington, DC, 1975; M. Vanryckeghem, Proceedings of the XXIVth Congress of the International Association of Logopedists and Phoniatrists, Nijmegen University Press, Nijmegen, 1981]. In addition, after performing speech and non-speech tasks, participants evaluated their level of anxiety on a subjective scale, labeled Task-Related Anxiety--TRA. The stuttering group also evaluated the level of severity of their stuttering. Findings indicate that trait anxiety is higher among people who stutter compared to fluent speakers, thus indicating that anxiety is a personality trait of people who stutter. State anxiety in social communication is higher among severe stutterers as compared to mild stutterers and fluent speakers. Thus, state anxiety is related to stuttering severity. The results are discussed in the frame of the multidimensional model of anxiety. EDUCATIONAL OBJECTIVES: The reader will be able to: (1) describe the multidimensional anxiety model; (2) extend the model to the relations between stuttering and anxiety; (3) describe stuttering severity in relation to the levels of anxiety within the model.

Adolescent↗
PubMed2006

Auditory abilities of speakers who persisted, or recovered, from stuttering.

OBJECTIVE: The purpose of this study was to see whether participants who persist in their stutter have poorer sensitivity in a backward masking task compared to those participants who recover from their stutter. DESIGN: The auditory sensitivity of 30 children who stutter was tested on absolute threshold, simultaneous masking, backward masking with a broadband and with a notched noise masker. The participants had been seen and diagnosed as stuttering at least 1 year before their 12th birthday. The participants were assessed again at age 12 plus to establish whether their stutter had persisted or recovered. Persistence or recovery was based on participant's, parent's and researcher's assessment and Riley's [Riley, G. D. (1994). Stuttering severity instrument for children and adults (3rd ed.). Austin, TX: Pro-Ed.] Stuttering Severity Instrument-3. Based on this assessment, 12 speakers had persisted and 18 had recovered from stuttering. RESULTS: Thresholds differed significantly between persistent and recovered groups for the broadband backward-masked stimulus (thresholds being higher for the persistent group). CONCLUSIONS: Backward masking performance at teenage is one factor that distinguishes speakers who persist in their stutter from those who recover. Education objectives: Readers of this article should: (1) explain why auditory factors have been implicated in stuttering; (2) summarise the work that has examined whether peripheral, and/or central, hearing are problems in stuttering; (3) explain how the hearing ability of persistent and recovered stutterers may differ; (4) discuss how hearing disorders have been implicated in other language disorders.

Adolescent↗
PubMed2006

Frequency of stuttering during challenging and supportive virtual reality job interviews.

UNLABELLED: This paper seeks to demonstrate the possibility of manipulating the frequency of stuttering using virtual reality environments (VREs). If stuttering manifests itself in VREs similarly to the way it manifests itself in real world interactions, then VREs can provide a controlled, safe, and confidential method for treatment practice and generalization. Though many researchers and clinicians recognize the need for generalization activities in the treatment of stuttering, achieving generalization in a clinical setting poses challenges to client confidentiality, safety, and the efficient use of a professionals' time. Virtual reality (VR) technology may allow professionals the opportunity to enhance and assess treatment generalization while protecting the safety and confidentiality of their clients. In this study, we developed a VR job interview environment which allowed experimental control over communication style and gender of interviewers. In this first trial, persons who stutter (PWS) experienced both challenging and supportive VR job interview conditions. The percentage of stuttered syllables was calculated for both interviews for each participant. Self-reported ratings of communication apprehension and confidence were also obtained, and were not significantly correlated with stuttering severity. Results indicated that interviewer communication style affected the amount of stuttering produced by participants, with more stuttering observed during challenging virtual interviews. Additionally, the amount of stuttering observed during the VR job interviews was significantly, positively correlated with the amount of stuttering observed during an interview with the investigator prior to VR exposure. Participants' subjective reports of the VR experience indicate reactions similar to those they report experiencing in the real world. Possible implications for the use of VR in the assessment and treatment of stuttering are discussed. EDUCATIONAL OBJECTIVES: After reading this article, the reader will be able to-(1) list some of the challenges to treatment generalization; (2) describe how virtual reality technology can assist in alleviating some of these challenges; (3) describe how the frequency of stuttering varies across two different virtual environments.

Adult↗
PubMed2003

The effect of syntactic structure upon speech initiation times of stuttering and nonstuttering speakers.

UNLABELLED: Past research has shown that adults who stutter tend to be slower than adults who do not stutter at initiating various speech-like movements, nonsense syllables, words, short phrases, and simple sentences. The present study sought to extend this research by examining the effect that syntactic structure has upon stutterers' and nonstutterers' ability to initiate sentences. Eleven persons who stutter (mean age=22.2 years) and 11 nonstuttering controls (mean age=23.3 years) read, rehearsed, and then reproduced a series of 96 sentences within a simple reaction time paradigm. The sentences were presented in four blocks of 24 sentences, and each block contained one version of each of the 24 base sentences. Versions of the base sentences varied, from simple to complex, along four levels of syntactic complexity. Results indicated that speech initiation times (SITs) were significantly longer for participants who stutter than they were for nonstuttering controls for three of the four sentence types. There was no significant difference in SITs across the four sentence types for either group. Among the stuttering participants, there was no significant correlation between stuttering severity and overall initiation time for the sentences. Consistent with other studies, the present findings suggest that persons who stutter are slower than persons who do not stutter at planning and/or initiating motor movements associated with speech production. EDUCATIONAL OBJECTIVES: The reader will be able to (1). describe how persons who stutter typically perform during various reaction time tasks, (2). explain the rationale for examining the effect of syntactic complexity upon speech initiation time, (3). discuss how the speech initiation times of persons who stutter compare to those of persons who do not stutter during the production of various types of sentences, (4). identify future research needs in this area.

Adolescent↗
PubMed2003

Tics and developmental stuttering.

BACKGROUND: Developmental stuttering affects 1% of the population but its cause remains unclear. Recent PET studies of metabolism in the central nervous system suggest that it may be related to dysfunction in the basal ganglia or its connections with regions of the cortex associated with speech and motor control. OBJECTIVE: To determine the presence and characteristics of involuntary movements (IMs) in people who stutter and to investigate the hypothesis that these movements may be of a very similar nature to the IMs seen in patients with movement disorders due to basal ganglia dysfunction. METHODS: Sixteen adults with developmental stuttering and 16 controls matched for sex and age were audio-videotaped while freely speaking 300 words in conversation and reading aloud 300 words. The audio data was inspected for dysfluencies and the video data was scrutinised for the presence and characteristics of IMs. RESULTS: Subjects who stuttered produced more IMs than controls during free speech (354 vs 187, p<0.05) and reading (297 vs 47, p<0.001). Most of the IMs in both groups were tics, with a greater number of both simple and complex motor tics (CMTs) in subjects who stuttered. CMTs were more frequent than simple motor tics in those who stuttered, but not in controls. The combination of repetitive eye blink followed by prolonged eye closure was found exclusively in the stuttering group, as were simple tics consisting of eyebrow raise or jaw movement. Dystonia in the form of blepharospasm was identified in a small number of subjects who stuttered. Choreic movements were not associated with stuttering. CONCLUSIONS: Developmental stuttering is associated with the presence of IMs that are predominantly simple and CMTs. This association suggests that tics and stuttering may share a common pathophysiology and supports the view that, in common with tics, stuttering may reflect dysfunction in the basal ganglia or its immediate connections.

Adolescent↗
PubMed1990

Validity and reliability of judgments of authentic and simulated stuttering.

This exploratory study was undertaken to determine if the concept has merit that the information by which a stutterer identifies stuttering at time of occurrence is qualitatively different from that by which listeners identify stuttering. If it is not the same, then perceptually equivalent stuttered and nonstuttered speech disruptions should be experienced by the stutterer as qualitatively different, even though recordings of these disruptions would sound alike to listeners. To test this hypothesis a criterion was developed to validate a stutterer's ability to accurately identify her stuttering at time of occurrence. She simulated her own stuttering and then judged acoustical recordings of authentic and simulated samples at five intervals following occurrence. Listener judgments were also obtained. Listeners were able to distinguish simulated and authentic samples with 57% accuracy. The stutterer's judgments were never inaccurate at time of occurrence of a speech disruption, but her accuracy decreased rapidly following occurrence, plateauing at 54%. These results supported the concepts that the production of stuttered and nonstuttered speech disruptions are experienced as being qualitatively different, that the difference is involuntary blockage, that only stutterers can validly recognize this difference, and only when it occurs, and that stuttering is a speaker/production rather than a listener/perceptual disorder.

Female↗
PubMed1989

Stutterers' self-ratings of speech naturalness: assessing effects and reliability.

Using single-subject experiments with 3 adult stutterers, this study evaluated the effects of instructions to stutterers to rate and modify how natural their speech sounds on experimenters' ratings of speech naturalness, stuttering frequency, and speaking rate. The study also included an investigation of the reliability of stutterers' and listeners' naturalness ratings. The stutterers were partway through a therapy program using prolonged speech or rate control. Results showed the stutterers could modify their speech so that their naturalness ratings increased or decreased. These changes were independent of stuttering or speaking rate. Experimenter ratings of speech naturalness were unchanged in conditions where stutterers judged their speech to sound more natural, but paralleled the stutterers' ratings when they judged their speech to sound more unnatural. An attempt to see if stutterers differed in their ratings of how natural their speech sounded or felt showed differences for one stutterer. Reratings of randomized session recordings by experimenters and independent judges showed that their ratings were highly reliable. When the same randomized session recordings were rerated by the stutterers (1 and 3 months after the experiment), their judgments of changes in their speech naturalness, which were not found in the experimenters' ratings, remained consistent and reliable.

Behavior Therapy↗
PubMed1990

Subvocalization and reading rate differences between stuttering and nonstuttering children and adults.

The hypothesis tested was that stutterers subvocalize more slowly than nonstutterers and that they need more time for the overt production of the fluent parts of their speech. We also investigated whether rate differences could only be observed for those words on which the stutterers expect to stutter. Fifty-nine school children (27 stutterers and 32 nonstutterers) and 19 adults (18 stutterers and 21 nonstutterers) performed a reading task in which a noun was presented together with its definite article. The presentation times of the reading material were controlled by the subjects. Half of the material had to be read silently, the other half orally. In oral reading, only the data from those trials without any indication of disfluencies were used. Dependent variables were presentation times, speech latency, and speech duration. The stutterers' silent presentation times were significantly longer than those of nonstutterers and this difference was significantly greater for children than for adults. In oral reading all stutterers, regardless of age, had longer presentation times, speech latencies, and article durations than the nonstutterers. Some nouns, however, were uttered significantly more rapidly by stutterers than by nonstutterers. These time differences were found to be independent of the stutterers' expectation to stutter. Our results indicate that a strictly motoric explanation of stuttering is inadequate. The data show that the stutterers and nonstutterers differ with respect to the temporal parameters not only during speech execution, but during speech planning as well.

Adolescent↗
PubMed1993

Genetic aspects of early childhood stuttering.

Although stuttering has long been acknowledged as a familial disorder, the nature of a genetic component remains unclear. Most previous data used in genetic studies were obtained primarily from adults who stutter and may be biased in several respects. The purpose of this investigation was to quantify the frequency of stuttering in relatives of preschool-age children who stutter, and who were first seen close to the onset of the disorder. Detailed pedigrees (family trees), including first-, second-, and third-degree relatives, were obtained from parents of 69 children who stuttered. We found, as have previous studies, that more male than female relatives ever stuttered, but that female subjects who stuttered had more female relatives who ever stuttered than did male subjects. In order to identify the genetic model most consistent with the observed patterns of stuttering transmission, we conducted segregation analyses. Results from these analyses suggest that transmission of a single major genetic locus increasing the liability to stuttering best accounts for the transmission of stuttering in families of preschool-age children who stutter.

Child↗
PubMed1997

Identifying the authoritative judgments of stuttering: comparisons of self-judgments and observer judgments.

Reliable and accurate stuttering measurement depends on the existence of unambiguous descriptions or exemplars of stuttered and nonstuttered speech. The development of clinically meaningful and useful exemplars, in turn, requires determining whether persons who stutter judge the same speech to be stuttered that other observers judge to be stuttered. The purpose of these experiments, therefore, was to compare stuttering judgements from several sources: 15 adults who stutter, judging their own spontaneous speech; the same adults who stutter, judging each other's speech; and a panel of 10 authorities on stuttering research and treatment. Judgments were mode under several conditions, including self-judgments made while the speaker was talking and self- and other-judgements made from recordings in continuous and interval formats. Results showed substantial differences in stuttering judgments across speakers, judges, and judgment conditions, but across-task comparisons were complicated by low self-agreement for many judges. Some intervals were judged consistently by all judges to be Stuttered or Nonstuttered, across multiple conditions, but many other intervals were either not assigned replicable judgments or were consistently judged to be Nonstuttered by the speaker who had produced them but were not assigned consistent judgments by other judges. The implications of these findings for stuttering measurement are considered.

Adult↗
PubMed2006

Cognitive processing load as a determinant of stuttering: summary of a research programme.

The present paper integrates the results of experimental studies in which cognitive differences between stuttering and nonstuttering adults were investigated. In a monitoring experiment it was found that persons who stutter encode semantic information more slowly than nonstuttering persons. In dual-task experiments the two groups were compared in overt word-repetition and sentence-production experiments. The results of the two word-repetition experiments indicate that the speech of stuttering persons is sensitive to interference from concurrent attention-demanding cognitive processing-particularly when phonological coding is involved. In two sentence-generation and -production experiments it was found that under dual-task conditions stuttering persons produced sentences containing a smaller number of content units whereas persons who do not stutter did not show a significant single- vs. dual-task contrast. These results suggest that sentence generation and production required greater sustained attentional processing in stuttering than in nonstuttering persons and that persons who stutter reduce the amount of "conceptual work" in order to keep their stuttering rates low. Data from an fMRI-study indicate that in persons who stutter the neural systems activated during sentence generation and production overlap to a greater extent than those of persons who do not stutter. It is suggested that in persons who stutter neural subsystems involved in speech planning are "modularized" to a lesser extent than in persons who do not stutter.

Adult↗
PubMed2004

The road to efficient and effective stuttering management: information for physicians.

Physicians are often the first point of contact when children's speech begins to be disrupted by stuttering behaviors such as sound repetitions and prolongations. For this reason, we feel it is important that they are accurately informed with regards to the nature of stuttering and the available treatment options before making referrals to speech-language pathologists. Stuttering is by definition, an involuntary disorder and remains that way throughout life. Its cause is still unknown and the only true form of remission appears to be the natural, spontaneous recovery that occurs in up to 80% of those children afflicted. No therapeutic course has seemed to change this figure and the prevalence of stuttering in the general population has remained stable, suggesting that speech therapy has never 'cured' stuttering. Therefore, we suggest that therapeutic intervention for stuttering should be best directed towards 'efficient' and 'effective' symptom reduction. Until recently, intervention options for children and adults who stutter have generally been limited consist of countless hours of speech retraining (teaching people 'how to talk again'), while attempting to bring the disorder under voluntary control. The common end-results of these procedures include unnatural speech patterns that are difficult to maintain in all situations and highly prone to relapse, thus, reinforcing the notion that stuttering is highly resistant to treatment. However, miniaturized digital technology now allows those who stutter to take advantage of auditory effects that 'inhibit' stuttering. 'Choral speech' or speaking in unison has long been known to make those who stutter immediately fluent without compromising speech naturalness. All in-the-ear devices can emulate choral speech effects by altering auditory feedback. Therapeutic protocols using these devices can be quickly and efficiently implemented. Furthermore, they are showing high levels of long-term effectiveness with regards to reducing stuttering frequency and maintaining speech naturalness.

Behavior Therapy↗