Recovery from Spastic Dysphonia By Direct Voice Rehabilitation
Overview & Symptoms
The etiology of spastic dysphonia remains in dispute. Some writers propose a psychological causation; others favor a neurological or physiological disturbance. Dedo, Townsend, and Izdebski state:
A possible hypothesis for an organic cause would include physical trauma or a viral infection in the peripheral or the central nervous system as a cause of selective disturbances in conduction and control of neural impulses from or to the larynx. (1978, p. 879)
However, medical examinations of my patients have not substantiated a neurological basis for spastic dysphonia. I agree with Weiss who states: "Spastic dysphonia is an extreme reaction of the patient to his anxiety centered around his vocal function." (1971, p. 81) I would add that the patient often reveals a voice neurosis rather than merely anxiety.
My clinical experience indicates that spastic dysphonia is functional in origin and may develop in three ways:
- Gradually and insidiously (period of years) due to long-term voice misuse and abuse.
- Quickly (period of months) due to voice misuse and abuse, to psychological trauma, or to physical trauma.
- Suddenly from a traumatic incident.
In the first two developmental types, spastic dysphonia may be preceded by incipient spastic dysphonia (a term I use to describe the earliest stage of spastic dysphonia), or it may appear as the entity known as spastic dysphonia. In this paper, only spastic dysphonia, and those patients diagnosed as having spastic dysphonia will be discussed. (It should be noted that a number of patients seen with spastic dysphonia report they had voice fatigue, nodules, polyps, or contact ulcer, prior to the spasticity.)
Psychological trauma as a causative factor may be a death, a divorce, an accident, possible or actual loss of job or position, or any comparable incident that affects the individual emotionally and is reflected in his voice, creating a dysphonia. This trauma may also be prolonged internal or external tensions such as feelings of inadequacy or personal insecurity.
Physical trauma may involve an upper respiratory infection or cold, a surgery, or a protracted severe illness. These physical factors may affect the larynx directly, creating voice misuse, or indirectly, creating physical fatigue or emotional depression which may lead to voice misuse through an inappropriate pitch of voice and laryngeal-pharyngeal tone focus. Hormonal imbalance, such as low thyroid condition, may contribute to an inability to maintain an efficient voice.
Patients with spastic dysphonia have a voice image and a voice identity which have contributed to the onset or continuation of their voice disorders by creating and continuing voice misuse and abuse.
The voice image involves the variables of pitch, tone focus, breath support, quality, volume, and rate. The voice image is initiated by psycho-social and internal demands and needs; it determines the type of voice the patient likes and uses or dislikes and does not use, and therefore, forms the voice identity.
The voice identity is the total sum of these individual voice variables into a composite voice that the patient identifies as his real voice. The voice image and the voice identity are the key emotional and psychological elements in the development, formation, and continuation of spastic dysphonia.
Spastic dysphonia is often referred to as a "strangled" voice. Spastic dysphonia sounds, as one patient described, "like talking with the brakes on."
The negative voice symptoms of spastic dysphonia may include:
- momentary or temporary cessation of voice
- abrupt and inappropriate voice changes in pitch, quality, and/or volume
- missed speech sounds
- a protracted choked or strangled sound
- severe laryngeal and pharyngeal tension
- extreme voice fatigue during and after speaking
- cording of neck muscles
- a choking sensation
- an effortful or forced voice
- an inability to talk voluntarily and at length in variable situations
The symptoms are self-perpetuating because of the emotional trauma of not being able to speak easily and spontaneously. Role and role situations are important and highly variable factors in spastic dysphonic patient’s ability or disability to speak.
Because of variations in symptomotology and because the voice may be clear or without spasticity at times, the diagnosis of spastic dysphonia may not be made by physicians and speech therapists. Individuals with this dysphonia usually experience physical tension and fatigue and extensive mental trauma.
Voice Rehabilitation Methods
Voice rehabilitation for spastic dysphonia involves pitch, tone focus, quality, breath support, and volume. The pitch of voice is inappropriate; therefore, the location and establishment of the natural or optimal pitch level and range are vital.
For some patients a supra-optimal pitch level or a basal pitch level is utilized initially; they are later directed to the optimal (natural) pitch level. This technique produces a faster laryngeal and pharyngeal muscle realignment to normal muscular movement for voice (Cooper, 1973). In spastic dysphonic patients, the tone focus is almost always within the laryngo-pharynx or lower throat, and always in this area when spasticity occurs. The tone focus must be altered to balanced oro-naso-laryngo-pharyngeal resonance, stressing at first oral and nasal resonance.
The voice quality of spastic dysphonic patients may be described as thin, strident, harsh, breathy, strained, etc. The quality is affected by the condition of the vocal folds, the resonators, the pitch, the tone focus, and breath support. In addition to these mechanical factors, emotional and psychological factors affect the quality. Because lower throat resonance does not carry and because this resonance area is stressed in spastic dysphonic patients, the volume produced is effortful, but also minimal. In addition, vocal fold spasticity is activated by this forced volume. As the patient develops oral and nasal resonance, he is able to produce more volume with normal effort.
The breathing pattern is erratic, irregular, and often reversed, that is, when the patient breathes in, the stomach goes in instead of going out. Even patients who breathe correctly tense the mid-section and hold the breath, so that the air flow for speech is not smooth. Some of these patients feel that they must wait until the end of the sentence to take a breath, so they squeeze out the residual air, constricting the muscles of the lower throat as well as the entire body. These patients have variations of wrong breathing patterns for speech. Mid-section breath support must be developed by all patients.
The properly used voice has a natural pitch and tone focus in the mask area which is supported by mid-section or central breath control. A competent voice therapist is able to determine the location of the natural voice almost immediately.
The method I use is simple, quick, and direct. The patient is asked to say 'um-hum' spontaneously and sincerely as if he is agreeing with someone. If the 'um-hum' is naturally and easily produced, the correct pitch level and tone focus will be heard. The patient will experience a ring, a tingling sensation, or a buzz in the mask area (area from the top of the bridge of the nose down to and around the lips). A holistic body technique which basically produces a correct pitch and tone focus is described as follows: The patient is instructed to sustain a hum (lips closed) while the therapist presses in a staccato fashion, on the patient's mid-section or higher (level of the solar plexus). This exercise, which I term the Instant Voice Press, can be taught to the patient who utilizes the press technique himself.
To support the correct pitch and tone focus and to eliminate the excessive laryngeal and total body tension, mid-section breath support must be used. The therapist first demonstrates correct breath support; the patient must be shown, not just told, how to breathe correctly. The patient must be cautioned not to tense the mid-section; the chest remains stationary while the stomach moves in and out smoothly and almost imperceptibly.
First the patient breathes gently and easily through the nose with the lips closed; next he breathes through the mouth in the same easy manner. The patient practices these two breathing exercises in three positions: supine; standing; and sitting. During each step, the patient places one hand on the chest and the other on the stomach as a self-monitoring device, removing the hands after developing a kinesthetic sensation. This breath control method is a simple, basic bio-feedback approach, utilizing the patient himself for self-monitoring and awareness of the breathing mechanism and breath support control. The therapist must realize that developing correct breath support takes time and must not pressure the patient. Voice quality is nearly always improved as the pitch and tone focus are altered and as mid-section breath support is developed. Volume also usually improves with the use of the correct pitch and especially the proper tone focus. It becomes less effortful with the use of mid-section breath support.
Following the location of the correct pitch, tone focus, and breath support, the patient works on carry-over. This includes exercises, such as 'um-hum' or humming at the optimal or natural level. The patient begins with 'um-hum', then 'um-hum one' (to ten), followed by 'um-hum' and a word, next 'um-hum' and a phrase, and lastly 'um-hum' and a sentence. The patient then progresses to natural conversation. The 'um-hum' method, as well as the Instant Voice Press, affords the patient an immediate fundamental self-monitoring device he can use anywhere to reestablish the correct pitch and tone focus. (A further modification of this method is to 'talk' using 'hum-hum-hum-hum' instead of words.)
During practice on these mechanical exercises and later during spontaneous speech, extensive use is made of two bio-feedback devices, the Voice Mirror, which visually displays pitch in lights instantaneously as one speaks, and the Bell and Howell Language Master, which provides an immediate audio replay. The patient is given his correct natural pitch range by the therapist; the patient develops this pitch by repeating it on the Voice Mirror and Language Master. This pairing of visual and audio feedback is combined with mid-section breath support so that the patient can see and hear the correct voice and can develop a kinesthetic feel for the natural voice as it is being produced. (A modified form of shock therapy utilizing a device strapped to the patient's wrist has been used with a few patients for carry over purposes from exercises to spontaneous speech. The therapist administers a mild shock when the patient reverts to the spastic voice in place of the natural voice.)
Correct and persistent practice is needed to enable the patient to carry over the correct pitch, tone focus, and breath support from therapy sessions to normal outside situations. The length of time needed to complete voice rehabilitation depends upon cooperation of the patient and the competence of the therapist. Location of the correct voice is immediate, simple, and direct; helping the patient develop habitual use of the new voice is challenging and demanding.
Because of the voice image and voice identity, the alteration in pitch, tone focus, quality, breath support, and volume, causes an immediate reaction, usually negative, by the patient toward the new voice. Patients say they 'sound like a robot.' Other comments are: 'I sound monotone; My new voice is unnatural; I am too loud; I am shouting.' Because the voice image and the voice identity are the core of resistance to use of the correct voice, voice psychotherapy is vital. Voice psychotherapy defines the old voice image and identity and establishes a new realistic voice image and identity which meet the patient's natural voice abilities. Without the patient's insights and understanding of his voice image and voice identity, and his acceptance of his new voice, new voice image, and new voice identity, he will revert to the old voice and remain dysphonic. Voice psychotherapy is one of the major determining aspects in the resolution of all voice disorders, especially spastic dysphonia.
Group voice therapy serves as a re-enforcement for individual voice therapy. The group provides an immediate human feedback for the correct and incorrect use of the voice. The voice image and identity can be explored and clarified, and a new voice pattern and techniques, as well as a new voice image and identity, can be learned in 'give and take' conversation with others. Patients often feel because a new voice is not acceptable to them (due to the old voice image and identity), it is not acceptable to others; the group serves as a means of support, reassurance, and carry-over. The new voice is re-enforced as the patient is reassured that he is not too loud, too monotone, etc., and the old voice is negated. The group affords a direct airing of emotional and psychological feelings and conditions that contribute or relate to the voice image, to the voice identity, and to the subsequent voice disorder. The group also serves as a release for feeling states and tensions concerned with the new voice. Groups consist of two to five patients.
Peripatetic voice therapy is another facet of voice rehabilitation. The patient (or patients) walk and talk with the voice therapist on the street, in restaurants, and in stores. In milieu voice therapy may be used in special cases; the voice therapist works with the patient at the actual site and under actual speaking conditions that confront the patient, such as a stage set, a gymnasium, factory, etc. In associate therapy, a relative, friend, or close associate is brought into one or more therapy sessions to provide the patient with emotional support outside of therapy and to assist the patient in the process of carry over from the therapy session to outside situations. In illustrative therapy, a former patient who has completed therapy attends one or more sessions to discuss the concepts, problems and relevance of voice rehabilitation with the new patient and to provide reassurance. In bibliotherapy, the patient is given articles concerning spastic dysphonia for further clarification and understanding of his problem and of voice rehabilitation. Bibliotherapy is used as a supplement, not as a substitute, for therapy. Patients are also encouraged to telephone the voice therapist at any time between therapy sessions as needed. The therapist helps the patient reestablish his pitch and tone focus or reassures the patient that he is maintaining his correct voice. All of these therapy techniques were developed to meet needs expressed by patients and to facilitate the process of voice rehabilitation.
In recent years a new treatment of spastic dysphonia by a surgical procedure has been used by Herbert Dedo, M.D. This surgery results in the paralysis of one vocal cord. Dr. Dedo stated in 1979 (p. 9) that: "Approximately one half of the people I operate on get a fairly easy, clear, phonatory voice immediately after their surgery has been completed." He continued: "Approximately 25% will need some speech therapy after surgery and these, then, are able to get a fairly reliable easy voice. There are another 25% who need more intensive voice therapy." Regarding follow-ups he stated (p. 10); "Basically we are finding that there are not a lot of people with late problems with the surgical procedure. It’s running about three to five percent with an excessively breathy voice, and about three to five percent who get some spasticity back."
Unfortunately, in my clinical experience, the spasticity is returning within a period of months to four years in a number of the post-surgical patients. I have worked with nine post-surgical patients, seven of whom I had referred to Dr. Dedo for the surgery. Most patients who were seen following the surgical procedure had voices that were free of the spasticity, and the voices were responsive to voice rehabilitation. Some of these patients developed excellent voices as I reported to Dr. Dedo. However, a recent follow-up revealed that six have returned to spasticity in varying degrees, two have hoarse, breathy voices (one of these two has had a teflon injection) and only one patient had a normal voice. Dr. Dedo’s findings (1976, p. 455) that "So far there has been no reversion to the severe preoperative spastic dysphonia..." has not been substantiated in my cases.
These less than optimal results have compelled me to reconsider this entire mode of treatment for spastic dysphonia. What I feel now is the most feasible method for those who select a surgical procedure is: (1) a program of voice rehabilitation following the surgery for all patients, and (2) of equal importance an on-going maintenance program on an as needed basis to retain voice efficiency over a period of years.
I think that the surgical procedure for some patients is a requisite trauma to long-term misuse of the speaking voice. The patient becomes, following the surgical procedure, more psychologically amenable to voice rehabilitation. Voice rehabilitation is usually necessary following any surgical procedure because the surgery does not alter old voice patterns/pitch, tone focus, breath support, etc. Voice psychotherapy is also necessary because the old voice image and voice identity may cause the patient to unconsciously attempt to use his old voice (pitch, tone focus) again. The surgery itself provides a brief time for voice rehabilitation to effect a change in voice habits before the possible return of spasticity. In addition, I now believe a voice rehabilitation maintenance program must be utilized. In my experience the surgery cure is temporary, and I believe that the surgery is failing because of a lack of continued post-operative voice rehabilitation.
Over the years, I have seen 71 patients with spastic dysphonia. The majority of these patients were seen for a voice evaluation only or an evaluation and limited therapy. Some patients were from out of town. Others, when told that voice rehabilitation would take from six months to a year or longer, did not wish to continue. Of the patients seen in voice rehabilitation without surgery, nine have recovered (with one known relapse after one year), and five are recovering.
The goal of voice rehabilitation in spastic dysphonia is for the patient to develop a normal voice which he can use in various situations, including the telephone, in conferences, in one-to-one conversation, and as needed. The patient must be taught behavioral modification so that he develops self-control of his own voice. This self-help program gives him the ability to monitor himself.
In summary, I would like to make the following points:
- Nine patients with spastic dysphonia have recovered and five patients are recovering through voice rehabilitation without surgery.
- From the patients I have seen, I believe that spastic dysphonia is functional in nature and that role and role situations play an important part.
- These patients have often had a history of long-term voice misuse and abuse; they have developed and maintained bad voice habits.
- Voice psychotherapy is essential to change the voice image and voice identity, the key emotional and psychological attributes in all dysphonias.
- Patients are referred for surgery if they request surgery, or if I feel that surgery will hasten the voice rehabilitation process by providing a hiatus in the long-term voice misuse and abuse. (This recommendation depends upon such variables as age, temperament, length of time the patient has had spastic dysphonia, severity of the spasticity, etc.)
- Patients can experience a resurgence of the spasticity after surgery alone, after surgery and voice rehabilitation, and after voice rehabilitation alone; therefore, patients must be taught self-monitoring and are also forewarned if they cannot maintain a normal voice, to return for booster sessions of voice rehabilitation.
I introduced "Dr. X," a patient who at this time had recovered 50% of his voice. A follow-up 4 years later found him to have an excellent voice.