From Issue 6 of:
"Advance for Speech Language Pathologists & Audiologists"
Feb. 1st, 1993
By Morton Cooper, PhD
Spasmodic dysphonia (SD) is considered to be a hopeless condition
by the medical profession and by speech pathologists. The treatment
of spasmodic dysphonia is to contain the symptoms, not to cure the
problem.
The center of the disorder is the basal ganglia, according to current
reports in the medical and speech pathology literature. I disagree
markedly with this position, finding the cause is voice misuse and
abuse, with psychological overtones. Over the past 20 years. I have
been finding successes and cures with Direct Voice Rehabilitation
(DVR).
My approach to spasmodic dysphonia is the same I use with all types
of voice disorders, as well as to improve the speaking voice from
a normal to a professional sound. In the treatment of disorders
and voices in general, I emphasize the variables of pitch, tone
focus and breath support. These are the three variables that affect
and control quality of voice as well as volume.
My essential approach to spasmodic dysphonia is to quickly locate
the optimal or natural pitch level and range within seconds of the
evaluation of the patients voice. The techniques to do this are
the instant voice press, humming "Happy Birthday" (first
bar) and the "um-hum" technique. Before I seek to change
the spasmodic voice, I take a history on tape of the patient and
pay attention to the laughter, the asides of the voice, the "um
hums" used, the clearing of the throat and coughing when it
occurs.
Despite the extreme severity in some cases, such as severe spasmodic
dysphonia, it is still possible to hear and locate the correct optimal
pitch level and range quickly. It is essential to listen to the
speaking voice and realize that spasmodic dysphonia is always coming
from the lower throat.
Securing an optimal pitch level and range is a vital attribute
to changing the spasticity of voice. Even though I can tell the
optimal or efficient voice, the essential item is to "refocus"
the voice from the lower throat to the mask (balanced oral and nasal
resonance). Pitch is merely a variable and quite often the most
responsive variable that allows the focus from the lower throat
to the mask area.
Step One is to have the patient sit before the Voice Mirror
to use the simple sound "um-hum." Nearly all patients
with spasmodic dysphonia can say the sound with the lips closed.
The "um-hum" sound is basically within the optimal pitch
level and range of where the voice should be. This level and range
is essentially at odds with and different from the pitch level and
range of the spasmodic dysphonic voice.
The "um-hum" places the voice in the mask, around the
lips and nose. It has not been utilized as a pitch pipe or method
although it serves the same function. The "um-hum" allows
the optimal pitch level and range and efficient tone focus as well
as a correct tone, all within the context of the "um-hum"
itself. This approach replaces the piano as the basic means of finding
the optimal pitch level and range by replacing it with the natural
sound of the individual spontaneously and sincerely saying "um-hum."
The efficient focus of the voice in the mask can be felt as a tingle,
buzz or ring about the lips and nose. The "um-hum" approach
relies upon the sensory feel by the patient to reproduce the correct
placment of voice. The mirror allows the patient to get visual feedback
by seeing the pitch level and range of the "um-hum" as
compared to the so-called normal voice, or spasmodic dysphonic voice,
where it is pitched in normal conversation.
The spasmodic dysphonic voice is esseentially pitched too low but
can be and is, at times, pitched too high. Regardless of whether
the pitch is either too high or too low, it is placed within the
lower throat and forced from the laryngo-pharynx. The "um-hum"
repitches the voice naturally and automatically and refocuses the
voice from the lower throat to the mask at the same time.
The pitch of the voice is correct for some spasmodic dysphonia
patients, but the focus is always from the lower throat, the one
place that nature will not allow the voice to be produced for normal
conversation per se.
Henry Kissinger utilizes the lower throat resonance but does not
force the tone or the focus from the lower throat. He allows the
sound to be "fried" taking from the basal range of his
voice. Were he to use energy while producing the voice from the
lower throat, he would be a possible candidate for spasmodic dysphonia.
Bill Clinton alternates between mask focus and lower throat focus,
creating the hoarse voice that we hear and which, in time, incapacitates
him from speaking. He, too, lets the voice sag into the lower throat,
trying to produce sound from this area, contributing to the impairment
of his speaking voice. He, too, is a possible candidate for spasmodic
dysphonia.
Spasmodic dysphonia is not the beginning or early symptom of a
wrong voice. More than not, it is the end or the completion of a
cycle of misuse that usually begins with a tired voice, fatigue
of voice or effortful voice that moves through nodes, polyps or
contact ulcer of the larynx.
Bowed vocal folds are also produced from the wrong focus of the
voice. Although this is considered neurological in cause, I find
it to be essentially functional and mechanical in nature. That is,
the individual is misusing the speaking voice, talking from the
lower throat with an inappropriate pitch level and poor breath support.
The reason I cite bowed vocal folds as a condition of on-going voice
misuse is because I attribute spasmodic dysphonia to the same type
of misuse that results in another type of dysphonia.
It is recognized that nodes, polyps and contact ulcers are
due to misuse of the speaking voice; it is not recognized that bowed
vocal folds and spasmodic dysphonia, as well, are due to misuse
and abuse of the voice.
To return to the technique of dealing with the misused or abused
voice. I take a step-by-step approach, concentrating on the location
of the optimal pitch level and range, while at the same time gaining
the focus in the mask with the individual repeating the "um-hum"
over and over until the contrast between the wrong pitch and tone
focus is seen and felt.
It takes but a few seconds to locate the basal pitch level of the
patient. I simply ask the patient to say "ah" or "oh"
or "ou" without forcing the sound. If it is not naturally
done, it can be a false bottom range which will then mislead the
clinician and the patient as to where the voice should be pitched.
The optimal pitch level and range should be approximately three
to four notes off the basal pitch level.
The ear of the clinician is the key to directing this whole procedure
to be right. The clinician must know what to listen for to acquire
the basal level of pitch and what to listen for in producing the
optimal pitch level and range with a natural "um-hum."
Some patients are inclined to force the voice from the lower throat,
producing the sound "um. "
THE "UM-HUM" breaks the pattern, but the "um-hum"
must be in the mask, not the lower throat. Again, there is no substitute
for the ear of the clinician. The vast majority of cases produce
the "um-hum" in the mask easily and naturally.
I work off this sound hour after hour until the patient gets the
feel of this sound in the mask. I then move to the "um-hum"
and the word, matching the "um-hum" to the word with the
same pitch level and focus. The patient can see the pitch level
and feel the focus. The patient essentially will keep the "um-hum"
where it should be but will drop the word in pitch and focus.
After this element is mastered, I have the patient progress to
"hum" and a word and then -hum- and a sentence, all at
the same pitch level and focus. I move to having the patient talk
spontaneously at this pitch level and focus, using a Language Master
for auditory feedback. The auditory feedback is used extensively
once the patient can see and feel the right pitch level and range
and focus.
Almost invariably, the patient complains that the new pitch level
and tone focus is producing a loud voice. This is the overwhelming
reaction of almost all patients undergoing Direct Voice Rehabilitation.
The volume image is a most vital psychological and emotional attribute
that must be understood by the clinician and the patient and dealt
with to the patient's satisfaction.
The patient finds the new voice which is dear and natural
and efficient--to be different, unfamiliar, artificial, "not
me", and loud. Over and over, they say they are shouting, and
the new voice appears to them to be aggressive if not overbearing.
The reaction to the new voice by the patient is not true. By introducing
the patient to others in the office and asking if others hear the
patient's new voice as being loud, the response is, "No, you
sound natural." I use this procedure over and over until the
patient is convinced that the new voice is normal.
I use peer pressure to make the patient use the new voice, not
only in the office but in outside situations. If the patient is
not convinced that the new voice is normal in volume, as well as
in focus and pitch, the carry-over to outside situations to normalize
and automate the right voice will not take place.
With all voice cases, I isolate the patient at the beginning, placing
the patient in a room by himself or herself and giving the patient
space to practice the variables of pitch and focus. Once they have
achieved this, I break the walls down and have them meet others
with similar voice problems.
I work on the breath support system after the tone focus and pitch
level and voice image have been encountered and resolved. Spasmodic
dysphonia patients reverse the breathing pattern. Rather than exhaling
as they talk, they hold their breath or let the air out quickly
on a word or two and continue talking or reverse the breathing pattern
so that the stomach pushes out when they talk rather than moving
in gradually and consistently.
TO UNDO THE WRONG breathing pattern, I have the patient lie flat
on his or her back with one hand an the chest and the other on the
stomach. I ask that the patient simply breathe in through the nostrils
as though going to sleep. It should be easy, uneventful breathing.
The patient can feel the midsection move out as air is taken in
but the chest does not move.
I ask the Patient to purse the lips on exhalation, allowing the
air to be exhaled while at the same time feeling the stomach moving
in gradually and consistently. This takes just a few moments of
time. I move the patient from the supine position to the sitting
position, using the same breathing exercises.
After the patient has the concept of the midsection moving out
on inhalation, I have the patient utter the sound "hum"
for four to five seconds on exhalation. The patient then blows out
the remaining air if there is any left. All the while, I have the
patient place one hand on the midsection to feel the stomach moving
out on inhalation and in on exhalation. I continue as I began with
the "um-hum," pairing it first with a word, then with
a sentence and then in spontaneous speech.
At this time I move the patient to meet with other patients until
the patient can naturally and automatically combine the breathing
with the tone focus under all types of circumstances. I remind the
patient when he or she is not monitoring the breathing, or if and
when the focus is not correct to self-monitor. The patient loses
the sense of fear, trauma or anxiety by openly discussing the variables
of voice and the method of recovery from the voice disorder itself.
Direct Voice RehabilitationFor recovery and cure of spasmodic
dysphonia or any dysphonia or voice improvement, a cooperative patient
and a competent voice clinician is essential.
The Rev. James Johnson. diagnosed by the Mayo Clinic as having
spasmodic dysphonia, had had this voice problem for eight years.
He declined surgery. He was cured of the problem within one month
of intensive DOW Voice Rehabilitation. He remains exceelent in voice
six years later. The Mayo Clinic acknowledges the fact that he has
recovered. (This patient had a contact ulcer before the onset of
SD.)
Gayle Pace, a patient at UCLA Medical Center, was diagnosed as
having abductor and adductor spasmodic dysphonia one year ago. She
declined a botulinum toxin injection. By a program of Direct Voice
Rehabilitation, she has recovered her speaking voice. Referred back
to UCLA for a phonatory work-up to compare her new voice to the
SID voice, she was found to have a normal voice. Gayle Pace remains
cured nine years after Direct Voice Rehabilitation in my office.
Marjorie Whitman was seen at the UCLA Medical Center and diagnosed
as having severe spasmodic dysphonia live years ago. She was unable
to produce a single word. She declined surgery. Through a program
of Direct Voice Rehabilitation over a period of years, she recovered
her normal voice. She is now able to talk under all conditions and
in all situations.
Rabbi Alan Green was diagnosed at the UCLA Medical Center with
spasmodic dysphonia approximately four years ago. Today, after completing
a program of Direct Voice Rehabilitation, he speaks with a normal
voice. He was referred back to UCLA for a phonatory analysis and
was found to have a normal voice. At that time, he was told he could
not have had spasmodic dysphonia because there is no recovery from
SD and the original diagnosis at UCLA must have been wrong. He reports
he is cured of his SD condition.
Twenty years ago Professor Fereydoon Taffozolli, PhD. was
referred to me by a prominent Los Angeles laryngologist, Hans von
Laden, MD. This patient had spasmodic dysphonia for which he underwent
a year-long program of Direct Voice Rehabilitation. He recovered
his speaking voice and remains cured in voice as indicated in a
20-year follow-up.
Lisa Andreson also was diagnosed as having spasmodic dysphonia
by a well-known laryngologist in Los Angeles. She was treated by
antibiotics but did not improve. A six-month program of Direct Voice
Rehabilitation helped her to recover a normal voice.
Edward Kantor, MD, a prominent laryngologist in Beverly Hills,
diagnosed Don Mathison as having spasmodic dysphonia. After five
months of Direct Voice Rehabilitation, the patient recovered from
SD with a better voice than he had had prior to the onset of spasmodic
dysphonia. (This patient was treated by DVR 10 years ago when he
had Polyps on the vocal folds. The polyps were eliminated within
a few months.)
Zelda Pollock, a teacher, was diagnosed by Robert Feder, MD, a
well-known laryngologist in Beverly Hills. After undergoing an intensive
six-month program of Direct Voice Rehabilitation, she recovered
her speaking voice. (This patient had polyps on the vocal cords
15 years prior to the onset of SD which were eliminated in three
months by DVR. She attributed the onset of the spasmodic dysphonia
to stress. Although she still has stress, she knows how to handle
her voice.)
Additional patients with spasmodic dysphonia are included on audiotapes
and videotapes before and after Direct Voice Rehabilitation.
The time period to complete Direct Voice Rehabilitation is variable.
You cannot put all patients into one category and demand they recover
quickly or at your pace, but at their own pace.
I believe that the Prognosis is excellent for all cases of spasmodic
dysphonia, but the patients have to be cooperative. Same patients
are more gifted than others. Same are more willing to change than
others and some are so resistant to changes they will never recover.
Failure to recover is cultural in part-an unwillingness by patients
to change or alter their voice image. They have no awareness that
they control this condition and cannot concieve that they we misusing
their voice.
A percentage of patients don't want to do something for themselves.
To change a long-term misused voice requires competent direction
and practice. They have to work at changing what is wrong to what
is right.
I liken it to a diet. People who am overweight and went a crash
diet don't essentially want to change their eating habits, so they
revert back. With the speaking voice, patients that fail, I find,
are essentially unable or not willing to put out the effort to make
the change and use the right efficient voice.
* About the author. Dr. Cooper is in private practice in West Los
Angeles CA. Previously, he was director of the Voice and Speech
Clinic as UCLA Medical Center. a clinical assistant professor of
the medical center's Head and Neck Division and director of the
Adult Stutterers Group at Stanford University He has authored four
books: Modern Techniques of Voice Rehabilitation (Charles C. Thomas.
1973). Approaches to Vocal Rehabilitation (Charles C. Thormas 1977).
Winning With Your Voice (Frederick Fell Publishers. 1989) and Change
Your Voice. Change Your Life (Harper & Row, 1985) |
