DVR Provides Hope for a “Hopeless” Condition
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 patient’s 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 placement 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 essentially 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 on 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 Rehabilitation For 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, has had this voice problem for eight years. He declined surgery. He was cured of the problem within one month of intensive Direct Voice Rehabilitation. He remains excellent 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 SD 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 five 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 Leden, 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 Matheson 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. Some 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 conceive 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 are 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.