Abdominal Breathing
The patient was seated in a comfortable, upright chair for back support and her posture checked and aligned. She was encouraged to drop her shoulders down
122 Voice Therapy: Clinical Case Studies
and to allow her abdominal muscles to relax. She then observed and moni- tored the movement of her abdominal wall, placing her hand on her abdo- men, low down, below the level of her waist. The therapist sat beside her and placed the back of her own hand over patient I’s hand to monitor the move- ment. The patient, likewise, placed the back of her hand over the therapist’s abdomen to feel the therapist model the desired breathing pattern. As the thera- pist breathed in, patient I observed her lower abdomen expand and then con- tract, moving inward on expiration. Gradually, the patient began to produce the same pattern, and the therapist syn- chronized her own breathing rate to patient I’s, having reminded her not to breathe too quickly or too deeply.
As a singer, patient I had little diffi- culty establishing abdominal breathing. When patients have difficulty, the early Accent Method exercises may be carried out with the patient lying supine so that the abdominal musculature can relax because these muscles are no longer required for postural support. This has the advantage of allowing patients to lie on their sides, which facilitates contrac- tion of the abdominal musculature on expiration, once abdominal breathing has been established.
Patient I was asked to repeat sounds modeled by the therapist. The initial sounds recommended are the voice- less fricatives /k/ (bilabial) /s/, /sh/, and /f/, repeated to form a rhythmic sequence designed to increase trans- glottic airflow. Gradually, the voiced counterparts /g/, /z/, /zs/, /v/, and close vowels such as /i/ and /u/ were introduced into the repeated sequences with emphasis on deliberately gen- tle, breathy phonation. At this stage, patients are encouraged not to breathe
in more deeply than they would for the previously established rest breathing, and the fricatives are made on elastic recoil rather than recruiting the abdom- inal musculature for controlling either the length or intensity of the sound.
Traditionally, little explanation is given to patients treated with the Accent Method; if errors occur, the therapist simply returns the patient to tasks he or she manages easily before gently increasing the complexity again. This therapist, however, does provide more guidance to patients, depending on their level of knowledge, experience, and skill, because it is vital to maintain the patient’s cooperation for a condi- tioning activity that can appear eccen- tric and mindless. At this early stage, if a patient continues to produce a low flow for fricatives, an overly long and con- trolled expiration, or both, this could be drawn to their attention. It also can be helpful for patients to notice that expi- ration stops naturally as lung pressure equalizes with the air pressure outside and that expiration pushed past this point requires muscular effort. This observation allows patients to locate any increased effort in the upper chest and strap muscles when they push past the rest position, which they can then correct.
The therapist monitors the vocal quality to ensure that the patient uses modal phonation. Voice onset may need to begin with breath before tone (ssszzzss) but should gradually become simultaneous with exhalation and pho- nation coordinated together. The vocal quality should become clearer but remain somewhat breathy. Phonation should be reliable and consistent as vocal fold clo- sure becomes uniform, with the midthird swelling displaced upward and away from the vibrating edge of the fold by
Primary and Secondary Muscle Tension Dysphonia 123
increased subglottic air pressure and air- flow. If these changes are not achieved, the therapist may need to return to an ear- lier stage, drawing the patient’s attention to any problems that have developed.
Other techniques can be incorpo- rated if necessary to provide a bridge from one stage to another, depending on the problem. For example, staying with “breath before tone” onset for longer periods ensures that the patient does not return to his or her previous hyper- adduction patterns, and introducing nasal consonants /m/, /n/, /ng/ usu- ally resolves closure problems and the wide glottic chink. Problems of contin- ued supraglottic tension often may be overcome using palpatory monitoring of the thyrohyoid space or the general laryngeal movement. Rarely is it neces- sary to resort to gentle glottal onsets to ensure modal voice, because this can usually be achieved using palpatory monitoring of the cricothyroid visor.
Gradually, patient I was encour- aged to produce gentle contractions of her abdominal musculature on expi- ration. The largo tempo (Figure 3–5) was introduced, in which expiration is punctuated by shorter, sharper rhyth- mic contractions of the abdominal mus- cles to produce stressed or “accented” beats. The largo tempo is slow, allowing
the patient time to coordinate expira- tion and the activity of the abdominal muscles. It also allows time for a rela- tively slow inspiration. The therapist and patient I continued to monitor the excursions of the abdominal wall while sitting and standing. Gentle rocking of the entire body may facilitate general relaxation and reinforce the rhythmic structure of the technique. The thera- pist then works the patient through the
andante (Figure 3–6) and allegro (Fig-
ure 3–7) tempos, gradually introducing other vowels and consonants until the patient can maintain the desired pho- nation pattern for babbling long, pro- sodic utterances of 20 minutes or more. Work designed to alter tongue position or oral-nasal resonance balance can be incorporated into the sound sequences at this stage. Other prosodic features, such as intonation (pitch contrasts) and dynamic (loud-soft) contrasts, can also be practiced.
As the patient gains confidence, meaningful words are introduced. Ini- tially, repetition of therapist-modeled utterances or rote-learned materials (such as rhymes or poems) are practiced before the patient graduates to sponta- neously generated utterances, such as responding to questions from the thera- pist or describing events.
124 Voice Therapy: Clinical Case Studies
Results
Patient I completed seven, 1-hour ses- sions of Accent Method voice ther- apy, which took place over 3 months between late February and May, with a 2-week break over the Easter holiday. The sessions were audio recorded, and patient I continued to practice the work at home on a daily basis. Reassessment in early June showed patient I to have improved significantly in her vocal health and voice production. Perceptu- ally, the patient’s voice continued to be slightly breathy, but the audible turbu- lent air escape present on her original recording had resolved.
There were no pitch or voice breaks, and the slow vocal onset initially observed
was no longer present. The “dead patch” in her vocal range had disappeared, and she was able to siren through her range smoothly and reliably. She still had to be careful to balance the air pressure and transglottal flow correctly while pro- ducing high and soft notes in her sing- ing, but otherwise her singing voice no longer gave her trouble. Her teacher reported that she was able to continue developing her singing skills.
Palpation of the extrinsic laryn- geal muscles showed that the tightness noted at her first assessment had largely resolved. All her scores had returned to neutral except those for the thyrohyoid muscles. Although these were judged as having reduced in score by half a scalar degree and were not reported as tender,
FIguRE 3–6. Andante.
Primary and Secondary Muscle Tension Dysphonia 125
they remained slightly elevated at 3.5 (neutral score 3). Patient I continued a slight tendency to raise her larynx dur- ing speech.
Videostroboscopy showed that patient I was now able to produce full vocal fold closure on phonation and that the midthird swelling had almost resolved. A little minimal thickening remained in the midthird that no longer appeared to be affecting phonation.
Patient I completed her final exami- nation at music college, achieving a good grade. She reported that her final recital had been well received and that she had experienced no difficulty with her voice despite a vocally demanding program.
In her treatment of a 44-year-old male, Rita Patel uses a specific approach of intensive voice therapy, first conceived by Diane Bless, PhD, at the University of Wisconsin Voice and Swallowing Center, to create a voice rehabilitation plan that includes components of intensive training and dynamic setup to facilitate carryover.
Case Study 15
Rita Patel
Voice Therapy Boot Camp in the Treatment of Secondary MTD in an Adult
Intensive short-term voice therapy is a new treatment approach that is being developed in the field of therapeu- tic management of voice to maximize behavior change for long-term recalci- trant dysphonia that has poor response to traditional direct voice therapy. Ther-
apy dropout, the ultimate nonadher- ence, is a common clinical problem in voice therapy.119 Given the limited avail-
ability of resources like clinical voice centers, the limited number of voice clinicians available to provide intensive voice therapy, and the limited number of graduate programs in which voice therapy is a focus of study, this new approach of intensive treatment has benefits, where target behavior change can be accomplished through concen- trated practice.
Principles of intensive voice treat- ment are derived from known literature in the fields of exercise physiology, inten- sive psychotherapy, and motor learning, which states that short-term intensive practice results in desirable physiologic changes120,121 and long-term retention
of newly acquired skills.122,123 It is well
known in exercise physiology literature that desirable physiologic changes from training occur primarily from intensity overload.124 Similar findings have been
noted with regard to intensive psycho- therapy. The findings from literature in psychotherapy support the notion of positive behavior change due to high levels of personal awareness and inten- sive practice, which leads to retention of newly learned skills. In the field of voice therapy, Lee Silverman Voice Therapy provides evidence for intensive voice therapy to improve laryngeal function in patients with idiopathic Parkinson disease.125 Behavior modification of
long-term refractory dysphonia other than of idiopathic Parkinson disease etiology continues to be challenging for voice therapists.
Like voice therapy, the goal of inten- sive short-term voice treatment regi- men is to maximize vocal effectiveness and behavior modification. However, unique to this approach of intensive
126 Voice Therapy: Clinical Case Studies
treatment is to bring these changes through techniques of concentrated practice, in the short term, in a dynamic setup that involves a maximum degree of experiences/challenges to achieve the desired target vocal behaviors.
An intensive short-term voice treat- ment program involves a highly struc- tured regime of multiple sessions with a variety of clinicians, incorporating multiple simultaneous voice therapeu- tic approaches necessary for the client. Part of these therapy sessions can also include additional voice/medical evalu- ations to clarify the nature of the client’s voice disorder. This form of intensive voice therapy provides rigorous prac- tice, involving not only overload, but also opportunities for specificity and individuality, thereby facilitating better transfer of learned skills. An intensive short-term voice treatment program involves voice therapy that is conducted in successive 1-day to 4-day sessions, for an average of 5 hours (range 4–6 hours) of voice therapy, with an average of 5 clinicians (range: 3–7 clinicians) per day. An intensive treatment program is not limited to a particular diagnosis/thera- peutic approach. Intensive short-term treatment is particularly beneficial for long-term recalcitrant dysphonia, where voice therapy continues to be indicated; when the patient has plateaued with a traditional form of individual voice ther- apy; when a patient has upcoming vocal performances within a short duration of initial assessment; and for clients travel- ing from longer distances to seek treat- ment at the voice center. Advantages of intensive short-term treatment are that it provides rigorous practice (overload), it provides opportunities for specificity and individuality, simultaneous inter- ventions can be conducted of multiple
components involved in voice produc- tion, opportunities facilitate transfer of learned skills, and these opportu- nities may influence patient compli- ance. A highly structured voice therapy regimen, an effective team leader, and communication between the clinicians providing treatment are important for successfully conducting intensive short- term voice treatment. The team leader is responsible for setting up intensive treatment, coordinating team meetings before and after treatments, and creat- ing a plan for transfer of information from one session to the next. The team leader is also responsible for follow-up with the patient after discharge from intensive treatment.
Patient History
Patient L, a 44-year-old male, a native of Iceland, was self-referred to the voice center for assessment and treat- ment of long-standing voice difficulty of 10 years. Patient L was accompanied by his wife for the session. The initial assessment was performed both by a voice pathologist and laryngologist. The patient was first examined by the voice pathologist, who obtained a detailed history of the nature and onset of the voice problem and a detailed medical history, and performed stroboscopy, high-speed digital imaging, acoustic analysis, aerodynamic assessment, and auditory perceptual analysis of voice quality. Subsequently, patient L was examined by the laryngologist, who reviewed the case history, stroboscopy, and high-speed examinations with the voice pathologist, performed indirect laryngoscopy, and performed a detailed head and neck examination.
Primary and Secondary Muscle Tension Dysphonia 127
Patient L reported a gradual wors- ening of dysphonia since its onset. Voice quality was reported to have reached a plateau in the past 5 years. The patient’s chief complaints were weak, strained voice quality and vocal fatigue. Voice quality was reported to deteriorate at the end of the day. Being an industri- alist, patient L had heavy voice use at work and outside of work. Individual meetings and presentations at board meetings constituted voice use at work. Social gatherings at restaurants with increased background noise comprised additional voice use. Frequent throat clearing was also reported. Throat clear- ing was reported to be productive dur- ing the morning hours. Patient L denied dysphagia or dyspnea.
Over the past 10 years, the patient was examined and treated by different voice centers across the country and internationally. Patient L was exam- ined by 1 otolaryngologist and 1 speech pathologist in Iceland, 1 otolaryngolo- gist in Germany, and 2 otolaryngologists in the United States. Impressions from these assessments were of laryngopha- ryngeal reflux, vocal fold scarring, glot- tal insufficiency, and vocal fold paresis. Patient L was treated with Omeprazole, 40 mg, twice a day, with no improve- ment of voice quality. At the time of the assessment, the patient was still tak- ing Omeprazole, 40 mg twice a day for reflux management. Patient L under- went unilateral right-sided injection laryngoplasty with Cymetra for glottal insufficiency and vocal fold scarring, in Germany. Due to no improvement of voice quality, patient L underwent left-sided injection laryngoplasty with Cymetra in the United States. Second- ary injection laryngoplasty also did not result in improvement of patient symp-
toms of vocal fatigue and hoarseness. Patient L did not undergo preoperative and postoperative voice therapy during the course of the dysphonia.
Patient L was a nonsmoker and consumed three 240-mL (8 fl oz) cups of water daily. Intake of 2 cups of cof- fee per day was reported. Patient L’s medical history did not reveal serious health conditions. He had no history of allergies, postnasal drip, and sinus infections. No evidence of hearing loss or injury to throat or neck region was reported. The patient’s medical history was significant for laryngopharyngeal reflux, which was confirmed with laryn- geal endoscopy, bariumesophagram, gastrointestinal (GI) endoscopy, and dual pH probe monitoring. Apart from the above-mentioned laryngeal surger- ies of unilateral injections for medializa- tion, patient L had not undergone other surgeries. Depression and anxiety were not reported.