Audio-Perceptual
When we met, patient Y’s only vocal- izations were utterances of vocal fry but with no accompanying lip, jaw, or tongue movements needed for word formation. These movements were not elicited even when the boy was asked to whisper. If it weren’t for the vocal fry productions, he might have been thought to show elective mutism. One got the impression that his talking was reduced to a series of vocal-fry grunts that may have showed syllabification, thought pauses, and interphrase silences. Additionally, the pitch and loudness of the grunts varied within restricted lim- its but seemed to suggest his attempts at prosody.
Instrumental Assessment
Visual Imaging. Previously completed during visits to an ear, nose, and throat specialist and was found to be within normal limits.
Acoustics and Aerodynamics. Not com- pleted in this case due to the patient’s limited vocalizations.
Patient Self-Assessment
There were no indications that the patient could reliably provide a self-assessment at the time of the evaluation. Additionally, this case study occurred prior to the common use of validated and reliable self-assessment tools. Today, we might have had the mother fill out a Pediatric Voice Handicap Index.
Voice Therapy
Specific Types of Therapy
Stretch ’n flow,36 gargle, general shaping
of voice production, and negative prac- tice37 were all used to achieve desired
target.
Rationale for Using the Therapy
The clinician is charged with identifying behaviors present, deficits present, and determining the next step/behavior the patient is capable of. The clinician must trust his/her knowledge of the voice-produc- ing mechanism and engage in a dynamic assessment of the patient’s abilities. This patient was unable to utilize traditional facilitative techniques; thus, Dr Stone began with increasing patient awareness and control of the respiratory system pro- gressing to articulated airflow in hierar- chical speech tasks while building patient
32 Voice Therapy: Clinical Case Studies
confidence. With neuromuscular reeduca- tion already begun, Dr Stone then used gargle to engage the vocal folds followed by successive approximations toward nor- mal phonation. Once this was completed, Dr Stone engaged in negative practice to confirm the patient was volitionally able to control the voice-producing subsystems. He was able to discuss the patient’s progress with the patient and his family and found them to be pleased with the patient’s prog- ress and prepared should the patient have difficulty in the future.
Therapy Goal and Expected Outcome
Return to within normal limits sound production to meet all vocal needs. Complete Description of
How to Do the Therapy
We will now return to Dr Stone’s account of the rationale and description of therapy. My involvement with patient Y was governed by a model I have called erg. In physics, an erg is a unit for measur- ing work. It involves moving a mass through a certain distance in a given unit of time. Applied to the therapeu- tic setting, one might consider taking a patient (mass) from one point of behav- ior to another (distance) within an indi- vidual therapy session (or segment of it) divided into three parts:
1. Evaluation of behavior or skill that is needed or (needs to be aban- doned) to bring the person closer to normal
2. Recommendation of desirable be- havior through verbal instruction and modeling
3. Getting on with developing the use of the desired skill (or absence of the undesired behavior) in a hierarchy of speaking situations
After the patient achieves success criterion at one level of the hierarchy, the erg is repeated at another level. Each recycling would involve a new bit of behavior. The bits are designed to shape the individual’s eventual performance into the use of normal physiology for phonation, finally in normal proposi- tion communication.38
The child’s potential for voice pro- duction using a variety of facilitative techniques,39 including inspiratory voice,
yawn-sigh, humming, throat clearing, coughing, and chewing was unproduc- tively probed.
Evaluating patient Y, initially, I sought to recognize those behaviors he brought to the task of communication that obviated normal voice production. Hollien40 has reviewed the character-
istics of vocal fry (pulse register) pro- ductions, suggesting there is increased glottal resistance and decreased airflow. Patient Y consequently needed to reduce muscle effort and increase airflow to the task of voice production. Teaching muscular relaxation41 of the interary-
tenoid, lateral cricoarytenoid, and thy- roarytenoid muscles to a 10-year-old child within 1 or 2 days (before he and his parents returned home several hun- dreds of miles away) seemed an unreal- istic clinical undertaking.
Recommendation, therefore, deem- phasized formal relaxation training and focused on increasing airflow. I learned quickly that asking patient Y to change behavior during speech-like activities led to failure. When a patient fails at a task that I recommend, I am obligated to
Primary and Secondary Muscle Tension Dysphonia 33
assume the responsibility for the error in asking something that is too difficult or in not adequately communicating what I want of the person. Because failure tends to foster undesirable thoughts in a patient and unproductive consequences of my guidance, I must present requests that the individual can understand and accomplish.
Teaching increased airflow, at what task could I expect patient Y to succeed? Finally, I merely asked him to blow against his upheld index finger as if he were blowing out a match. This was nonpropositional use of airflow and was a request of a behavior with which he had previous experience. It was behavior that easily could be molded by later instruction and was a task with a simplicity that anyone with normal anatomy could do. The component or partial behaviors to which patient Y’s attention was drawn through verbal instruction included unimpeded inspi- ration, no holding of the breath between inspiration and expiration, and lack of work (muscular action) in the neck area (and consequently in the larynx) on exhalation. These partial behaviors were adopted, then, as the recommended behaviors to be employed repetitively (that is, practiced, which constitutes “getting on with the behavior”) in a vari- ety of tasks one might consider as con- stituting a speaking-situations hierarchy. Lowest on the hierarchical lad- der was purposeful flow of air through the untensed speech mechanism. Next, patient Y practiced flow of air while his mouth and lips were placed in various static positions. This was done by ask- ing that he produce a relaxed flow of air with his mouth open, then somewhat closed with the corners of the lips pulled back, then with lips rounded, and so
forth. (These positions resulted in the production of different whispered vow- els; however, this fact was not pointed out to patient Y because of the need to avoid the chance of failure that might have accompanied a request to “whis- per /i/, whisper /a/,” for example.)
After the boy successfully produced multiple events, meeting at least 80% success in the desired partial behaviors while instruction (discriminative stimu- lus) and positive feedback were with- held, it was pointed out that he indeed produced many tokens of various vow- els. He then was asked to practice pro- duction of airflow (no voice) on vowels that he read from flash cards. (This rep- resented another level of the hierarchy: purposeful vowel production with flow of air through an untensed mechanism.) The use of unvoiced flow of air through a relatively relaxed speech mechanism was eventually shaped through care- fully graded increments of a speaking hierarchy into employment for propo- sitional speech. At this point, after approximately 1 hour of intervention, patient Y was whispering normally. Mouth, lip, and tongue movements had become reestablished communication behaviors along with unimpeded flow of air. Not only had an erg been accom- plished, but the idea of elective mutism as a diagnostic label no longer was an appropriate consideration.
The second session began with an evaluation of what behavior was needed to bring patient Y a step closer to normal communication. Even the uninitiated clinician would recognize the patient’s need for vocal fold activity superim- posed on the flow of air through a rela- tively relaxed speech mechanism. But how could vocal fold activity be recom- mended without a statement such as,
34 Voice Therapy: Clinical Case Studies
“OK, now produce the airflow like you did last hour, but this time with voice?”
The reader also may ask, “What’s wrong with asking for voice?” Maybe nothing would be wrong, but I submit that it would have risked the patient adopting behaviors similar to those he demonstrated when he first entered therapy (which was vocal fry). Guarding against this possibility, I was compelled not to refer to “voicing.” Also, I did not want to ask the patient to do any of the activities previously requested because he failed at them. What could I do that might rely on referents that the child knew, that were not requests “to produce voice” (because he “knew” he couldn’t produce voice), and that would ensure success?
I decided to approach voice pro- duction by recommending gargling. Unvoiced gargling really wasn’t much different from the activity patient Y had engaged in during the previous hour. The recommendation proceeded as fol- lows, where C is the clinician and P is the patient.
C: “I know you can let air flow out of your mouth. This time I’d like you to do so while gargling a small mouthful of water.” (Clinician models, tilting the head backward and gargling with voice.) “Now you do it.”
P: The patient tried. He produced the bubbling sound, but no voice. C: “Okay, you kept the air flowing out all the time. That’s a good thing, too! If you hadn’t, you’d have done a lot of choking. Keeping the air going is pretty important. Now, this time let’s have you gargle like your Dad might do — with a lot of sound.” (Clinician models vocalized gargling.) “Now, you do it.”
P: The patient tried. He produced the bubbling sound louder than before, but still no voice. After he swallowed the mouthful of water, he gave a little laugh with one short period in which the voice was produced in a high-pitched squeal sound.
C: Immediately, the clinician
remarked, “Hey, did you notice that part of your laugh had some voice to it? Here, gargle another sip of water and make that little squeak sound as you gargle.”
P: Patient Y succeeded.
C: “Do that again, but this time make the sound longer.”
P: Again, patient Y succeeded. C: “This time, make your gargle sound bigger, like your Dad might sound.”
P: Again, patient Y succeeded. C: “Okay, this time make that sound, but without using a sip of water.”
P: Again, the patient succeeded. Voice was produced, and the gur- gling sound probably resulted from interruption of the voice airstream by repetitive action of the uvula against and away from the base of the tongue.
Practice followed until the patient and the clinician both felt assured that this behavior could be repeated any time the patient wished. The next evaluation established the need to alter the boy’s head position to an upright posture.
Accomplishing this was done in three trials in which gradual increments of head position change minimized the potential for failure that might have
Primary and Secondary Muscle Tension Dysphonia 35
accompanied moving the head in a sin- gle trial to a position more suitable for communication.
Next, the evaluation established the need to alter the gurgling of sound to a continuous voice production by eliminating the tongue-uvula vibration. The recommendation to the patient was a simple instruction to open the mouth widely (separating the tongue from the uvula) accompanied by providing a mode of sustained /a/. Five trials were done before the patient indicated that he felt able to do this consistently when- ever he wanted.
The next intervention step needed to establish patient Y’s ability to main- tain continuous voice while moving parts of the speech mechanism with- out triggering his dysphonic behaviors conditioned to the act of speaking. The recommendations involved leading the boy, by modeling, through a sequence of behaviors starting with opening and closing the mouth (vowel productions) with continuous voice. Next, vowel-like utterances were made individually rather than the continuous vowel series. Following this, individual vowel pro- ductions each were terminated with an articulatory valving; then, vowels were initiated and terminated with conso- nants. Even though patient Y was pro- ducing nonsense and finally meaning- ful syllables at this time, the fact that he merely was copying the model set by the clinician seemed to keep him from recognizing that he was using voice in speech-like units. Finally, after the boy had produced several CVC units that would have resulted in meaning- ful words if they had been uttered in reverse, it was pointed out that the patient had been saying words back- ward. For example, “tube” said back- ward would be “boot.” “You have been
speaking backward, let’s now say some words forward,” was the recommenda- tion used to elicit meaningful words.
Use of words to form phrases and sentences was based on increasing the length of utterance, word for word, and then finally uttering the entire unit. For example
C: “Say ‘I’.”
P: “I.”
C: “Say, ‘I want’.” P: “I want.”
C: “Say, ‘I want some’.” P: “I want some.” (etc, etc)
P: “I want some eggs for breakfast.” By the end of this session (2 hours), patient Y was able to engage in dia- logue, maintaining voice that was differ- ent from that with which he presented initially and was closer to normal. The voice still had a falsetto-like quality and was produced with guarded participa- tion. I decided to accompany patient Y and his parents to lunch and observe the degree to which the boy maintained his present skill outside the clinical set- ting. He did admirably. Not once did he lapse into vocal fry, and during lunch he even seemed to modify voice pro- duction to be more normal. After lunch, intervention resumed and constituted a review of the processes the boy had used in reacquiring use of voice. With a trend during lunch for him to improve voice toward normal, formal activities focusing on voice normalization were deferred until the next day.
Patient Y returned the next day, and his parents vouched for the accuracy of his contention that he had maintained use of the improved vocal function
36 Voice Therapy: Clinical Case Studies
established during the previous after- noon and evening. Although he pre- sented this morning with normal voice, I was uncertain of his awareness of the clinical processes and goals. To test this, I asked the boy to demonstrate the way he talked before we started intervention. He did. Then, he successfully switched at will between normal voice and that which he used previously.
One last evaluation seemed nec- essary. Because patient Y lived nearly 300 miles away, and he could not con- veniently return to the clinic, I needed satisfaction that he knew what to do to reestablish normal voice if he ever began speaking with his pre-intervention be- haviors. Notice the absence of the term
remission. Within a behavioral model of
intervention, the use of medical terms such as remission, exacerbation, and cure tend to be used in ways that do not fos- ter a patient’s development of the aware- ness that the behavior brought to the task of speaking is the responsibility of the patient. I was seeking indication that this patient had become his own clinician and that he had an appropriate plan of approach to solving future problems of voice of a similar nature should he exhibit them. Patient Y reiterated and success- fully demonstrated the intervention steps he used to reestablish normal voice.
Because his parents participated in the therapy sessions, it seemed impor- tant to sample the parents’ understand- ing of how their son implemented a change to normal and the implications of this change. This was assessed on the second morning through an interview at the end of the patient’s hour-long session.
C: “What thoughts went through your mind as you and the family were experiencing this?”
M: “Well, we were told that our son’s problem was purely psychological, that until he could learn to cope with a lot of the fears and things that were going on inside of him he would not be able to produce a voice that his subconscious would not allow him to speak. So we went through a whole lot of guilt and embarrassment. I think that each one of us wondered . . . were we the ones who caused that kind of trauma and what have we done when we thought that we had a typical, normal family. You know there was a lot of self-doubt and wondering if he would ever get over this.”
C: “Pretty spooky!”
M: “Yes, it was very scary, yup.” C: “Do you have any concerns or questions now that you know he is producing voice again?”
M: “No, I don’t think so; I guess, if he comes down with laryngitis I will be very nervous. I think I am really satisfied with the psychological end of it and . . .
C: “Explain what you mean.” M: “Well, I guess I worried about a lot of deep-seated problems and, you know, I don’t think I am worried about that anymore. In the beginning, I would have said if he had gotten his voice back maybe there would be another time when if a traumatic experience occurred, he would lose it again. I see it now more as a physical thing that he can deal with and we can help him if he, you know, if it would come to a point where there was a problem
Primary and Secondary Muscle Tension Dysphonia 37
with voice, I think we would know how to handle it.”
Frequency and Duration of Treatment
Patient Y was seen for approximately 5 hours across 2 days. Dr Stone addition- ally accompanied the family to lunch. This was consistent with how patients were often treated when I was employed with Dr Stone at the Vanderbilt Voice Center. We often saw patients for multiple, consecutive sessions over several days due to distances patients had traveled or lack of qualified resources near their homes. We found this type of treatment to be very effective. Recently, the University of Wisconsin has written about a similar intensive program they refer to as “boot camp” which has initially promising results. It should be noted that an impor- tant aspect of boot camp, which differs from this account, involves use of multiple thera-
pists.42 (See Case Study 15 by Rita Patel,
Voice Therapy Boot Camp, presented later
in this chapter, for more information.)