Patient K underwent reevaluation of baseline measures 7 months follow- ing therapy termination, which cor- responded to 10 months post baseline. Results are shown in Figures 3–12 to 3–15. Figure 3–12 displays a post-therapy
image from her post-treatment strobo- scopic exam and can be compared with Figure 3–8. The blinded laryngologist, who rated her pretherapy exam, also rated her post-therapy strobe exam at the same time, again blinded to the pur- pose of his ratings. For post-treatment images, the laryngologist noted a change in glottal shape from hourglass to having a posterior glottal gap, con- sidered normal. Vocal fold edges, ampli- tude of vibration, and mucosal waves all normalized.
The treating speech-language pa- thologist and 2 blinded cohorts who also rated K’s pretreatment audio recordings provided post-treatment evaluations of voice using the CAPE-V procedures. Average and range of post-treatment results for the 3 raters are shown in Fig- ure 3–13 along with pretherapy ratings for comparison. Post-therapy, raters agreed that all voice quality parameters were well within normal limits.
In addition, post-treatment patient K completed the VoiSS, the S-VHI, and the nonvalidated clinical questionnaire. Results for the VoiSS and S-VHI are dis- played in Figures 3–14 and 3–15, both
FIguRE 3–12. Posttreatment still image of vocal folds.
Primary and Secondary Muscle Tension Dysphonia 155
showing marked improvements from baseline. Using the unpublished clinical questionnaire, post-therapy K rated her voice at 94% of normal voice on a visual analog scale (compared to 32% prether- apy), she rated her concern about voice as a 2/7 and vocal effort in speech as a 1/7 (compared to 5/7 and 4/7, respec- tively, pretreatment).
Most important were patient K’s results relative to specific therapy goals. Functionally, K felt that she had obtained her goals of speaking normally, without discomfort during most speech. She no longer experienced fatigue dur- ing social or occupational conversation,
and she was able to sing more consis- tently and without discomfort. At the 7-month post-therapy follow-up, both the treating clinician and the blinded raters judged K’s voice to be normal 100% of the time in connected speech, and the treating clinician considered her voice normal 95% of the time in conver- sational speech. As noted, K herself felt she was doing well with her voice and rated her post-therapy voice at 94% of normal compared to 32% of normal at baseline. She did feel that she still had to be mindful of her voice use in social situations and would occasionally have mild vocal fatigue.
FIguRE 3–13. Comparison of pretreatment and posttreatment CAPEV scores, averaged across 3 raters (for each parameter 100 is worst pos sible score). For pretreatment score ranges, see Figure 3–9. Posttreatment ranges were overall grade: 2 to 5; roughness: 0 to 2; breathiness: 0 to 1; strain: 0 to 0; pitch: 0 to 0; loudness: 0 to 0.
156
FIguRE 3–14. Comparison of pretreatment and posttreatment scores for Voice Symptom Scale (VoiSS).139 Worst possible scores
are total score = 120; impairment domain = 60; emotional domain = 32; physical domain = 28.
FIguRE 3–15. Comparison of pretreatment and posttreatment scores for Singing Voice Handicap Index (SVHI).140 Worst pos
sible scores are total score = 144; functional domain = 40; physical domain = 40; emotional domain = 64.
Primary and Secondary Muscle Tension Dysphonia 157
Medical goals for K were also achieved. Post-therapy, her vocal folds appeared white with straight edges except at the highest pitches for which subtle marginal irregularities were noted.
Based on medical and biomechani- cal findings at treatment termination, the treating clinician recommended that K continue using stretches and reso- nant voice exercises at least 3 to 4 times weekly, prophylactically, and that she work with a local singing voice teacher. Following discharge from active ther- apy until her 7-month follow-up, K had about 2 singing lessons with a local teacher but was dissatisfied with them. She then followed up with 4 to 5 lessons with a singing voice specialist prior to her clinical follow-up.
Conclusion
Lessac-Madsen Resonant Voice Therapy
(LMRVT) was used to address the
functional concerns of a female singer who presented with chronic vocal fold nodules and functional consequences thereof. All measures, including blinded measures by clinicians otherwise unin- volved in her care, indicated striking functional and medical improvements as a result of this treatment, achieving normal status. The patient’s functional and medical goals were met. Princi- ples described for this patient may be applicable to other patients with voice disorders involving hyperadduction or hypoadduction of the vocal folds.
Acknowledgments. The writing of this section was partly supported by Grant No. R01 DC008567 (Verdolini Abbott, Principal Investigator) and R03DC012112-01 (Li, Principal Inves- tigator) from the National Institute on
Deafness and Other Communication Disorders.
In the following case, Tara Stadelman- Cohen, Jarrad Van Stan, and Robert Hillman demonstrate the potential future role that ambulatory biofeedback may play in voice therapy. The
Ambulatory Phonation Monitor (APM, KayPENTAX, Inc.) provides patients with unobtrusive real-time vibratory feedback regarding pitch and loudness as they go about their normal daily activities. When used to reinforce thera- peutic goals in natural environments, ambulatory biofeedback has potential to facilitate the carryover phase of voice therapy.
Case Study 19
Tara Stadelman-Cohen, Jarrad Van Stan, and Robert E. Hillman
Use of Ambulatory Biofeedback to Supplement Traditional Voice Therapy for Treating Primary MTD in an Adult Female
Case History
History of the Problem
This 41-year-old female presented with a 4-year history of vocal strain and fatigue, increased dysphonia, and neck muscle pain/discomfort associated with voice use (particularly at the end of a work- day), all of which corresponded with the onset of a new job. She had been pre- viously diagnosed with primary muscle tension dysphonia (MTD) at another
158 Voice Therapy: Clinical Case Studies
institution where she also received a full course of voice therapy along with bilateral Botox injections. The previous treatments failed to resolve her voice problems that the patient attributed to an inability to feel and hear differences in voice production. She reported that she could “mimic” voice therapists well during therapy sessions, giving the false impression that she was fully integrat- ing the desired therapy goals, but there was little, if any, carryover.
Medical History
Past medical history included multiple head and neck surgeries (tonsillectomy, partial thyroidectomy, and oral sur- gery), thyroid disease, GERD/LPR, and environmental allergies. Current medi- cations were loratadine for seasonal allergies, levothyroxine for thyroid dis- ease, and budesonide nasal spray.
Voice Evaluation
A complete voice evaluation was per- formed which included physical exami- nation, auditory-perceptual assessment, acoustic and aerodynamic assessments, endoscopic laryngeal imaging with stro- boscopy, and patient self-assessment of vocal function.
Physical Examination
Upon palpation, the larynx was severely elevated with minimal thyrohyoid space. Reduced lateral and anterior range-of-motion of the hyoid and thy- roid lamina was also evident. Evidence of musculoskeletal misalignment was reflected in heel weighting, locked knees, mildly forward pelvis, posterior shoulders, and forward head position.
Audio-Perceptual Assessment
Auditory-perceptual evaluation was performed by the examining clinician using the standard CAPE-V,90 and those
results are shown in Table 3–11. The patient’s voice was judged to be con- sistently mildly-moderately dysphonic with associated features of inconsistent mild roughness and breathiness, incon- sistent moderate strain, and inconsis- tent mild-moderate increased pitch and loudness.
Acoustic and Aerodynamic Assessment
Acoustic and aerodynamic testing were performed in a sound-isolated room as the patient performed a set of stan- dard voice and speech tasks. Results are shown in Table 3–12. The patient dis- played abnormally high levels of acous- tic perturbation (jitter and shimmer), average fundamental frequency, and average sound pressure level. Her max- imum pitch and loudness ranges were abnormally restricted. Aerodynamic measures were all within normal limits. Laryngeal Endoscopy
With Stroboscopy
Both transnasal flexible and transoral rigid endoscopic examinations were performed to evaluate vocal structures and function. The patient had excellent abduction and adduction of her true vocal folds and arytenoid cartilages. There was an inconsistent temporal asymmetry of motion with the left vocal fold appearing more restricted and slug- gish in its motion than the right vocal fold. This was observed to resolve after several minutes of visual monitoring with flexible endoscopy, thus ruling out
Primary and Secondary Muscle Tension Dysphonia 159
paresis of the left true vocal fold, and was instead attributed to vocal hyper- function. During modal phonation, the patient attained good glottal closure with phase symmetric mucosal waves indicating good pliability of the under- lying superficial lamina propria layer. As she approached higher frequencies, she displayed symmetric elongation of the true vocal folds, signifying intact
function of the external branches of the superior laryngeal nerve bilaterally. The patient’s voice appeared to be clearer and less effortful as she produced pitches above the normal female range (>230 Hz). When asked to phonate at normal female frequencies between 200 and 230 Hz, the patient had evidence of significant supraglottic muscle hyper- function and a less clear tone.
Table 3–11. Pretreatment and Posttreatment Measures for the CAPEV
CAPE-V Results for Voice Quality Voice Quality
Dimension PretreatmentEvaluation Post-TreatmentEvaluation
Overall severity 35 (C, mildmod) 14 (C, mild)
Roughness 17 (I, mild) 8 (I, mild)
Breathiness 16 (I, mild) 4 (I, mild)
Strain 49 (I, mod) 33 (I, mildmod)
Pitch 35 (I, mildmod increase) 11 (I, mild increase)
Loudness 24 (I, mildmod increase) 0 (C, normal)
Resonance I, decreased oral
resonance I, low tone focus
Additional features None I, glottal fry
The scale is 0 = normal to 100 = severely deviant.
C represents “consistent,” and I represents “inconsistent.”
Table 3–12. Pretreatment and PostTreatment
Measures for the VRQOL
Voice-Related Quality of Life (V-RQOL) Results
Scores Pretherapy Evaluation Post-Therapy Evaluation
Total VRQOL 43 78
Socialemotional 31 75
Physical functioning 50 79
The scale is 0 = lower quality/functioning and 100 = higher qual ity/functioning. Significant posttreatment improvements can be seen when compared to pretreatment.
160 Voice Therapy: Clinical Case Studies
Patient Self-Assessment
The patient completed the Voice-Related Quality of Life (V-RQOL)102 inventory to
assess the impact of her vocal difficulties on her daily function. The V-RQOL gen- erates a total score and two subscores related to physical and social-emotional functioning; scores on all scales range from 0 (lower quality/functioning) to 100 (higher quality/functioning). Results are shown in Table 3–13. The patient dis- played scores in the midrange (physical functioning) or below (total score and social-emotional functioning) indicat- ing that the patient’s voice problem was having a significantly negative impact on her daily function/quality of life.
Voice Therapy
The primary focus of therapy was reduc- tion of muscle tension in extrinsic neck and intrinsic orolaryngopharyngeal musculature during both voiced and nonvoiced activities. Treatment modali- ties included paralaryngeal massage and manipulation,19,44 laryngeal man-
ual therapy,23,83 tongue range-of-motion
tasks (eg, extension), and suboccipital release.179 Musculoskeletal realignment
was also addressed by achieving a bal- anced plumb line from the ears to the shoulders, pelvis, knees, and ankles with attention to freedom of movement in seated and standing activity.180 Addi-
tional treatment goals were reduction of breath holding, shallow breathing, and speaking too long on one breath. Education regarding the anatomy and physiology of voice and speech sub- systems was also provided to improve the patient’s ability to prevent difficulty through a greater understanding of how the voice works.
During phonatory tasks, particu- lar emphasis was placed on maintain- ing an average vocal pitch (fundamen- tal frequency) that was slightly higher than what is considered normal for an adult female (>230 Hz). This was based on the observation during the evalu- ation that the patient displayed clear signs of hyperfunction when her pitch dropped into the normal range (ie, low- ered pitch served as an indirect indica- tion/sign of hyperfunction but was not considered to be the cause of the voice problem). Real-Time Pitch (KayPEN- TAX) was used intermittently during voice therapy sessions to provide visual biofeedback based on fundamental fre- quency to reinforce the goal of main- taining a higher pitch while at the same time cueing into the associated reduc- tion in hyperfunction. The biofeedback function of the APM was used with this patient because she failed in previous courses of voice therapy to carry over techniques outside of the therapy ses- sion and the drop in pitch associated with her hyperfunctional voice pattern could be targeted by the APM. Biofeed- back is meant to provide a patient with information the patient is otherwise unable to acquire (eg, fundamental fre- quency),181 and it is hoped that when
applied on an ambulatory basis, bio- feedback can concretely extend therapy techniques into contextual, real-life situ- ations. The APM uses an accelerometer (ACC) placed on the neck just above the sternal notch to sense phonation. The ACC signal is processed by a small digital device (worn in a belt pack) to extract estimates of vocal fundamental frequency, sound pressure level, and phonation duration. The device pro- vides biofeedback to the patient wear- ing it via a pager vibrator worn on a belt based on thresholds for fundamen-
Primary and Secondary Muscle Tension Dysphonia 161
tal frequency and sound pressure level which are set by the clinician. In this case the APM was set to provide 250 ms of vibrotactile feedback when the fun-
damental frequency fell below 250 Hz for 500 ms or longer.
The APM was introduced after the initial evaluation, and the patient was
Table 3–13. Pretreatment and PostTreatment Aerodynamic and Acoustic Measures
Vocal Function Measures
Acoustic and Aerodynamic Analysis Results Tasks and Measures
(Abnormal Values) Normal Values PretherapyEvaluation Post-TherapyEvaluation
Steady Vowels Jitter (%) ≤1.04 1.9% 1.86% Shimmer (%) ≤3.81 5.6% 1.94% Noise (NHR) ≤0.19 0.12 0.104 Reading Average F0 (Hz) 180–230 253.37 Hz 261 Hz Average SPL (dB) 67–73 81.2 dB 69 dB Maximum Performance Lowest pitch (Hz) — 175.44 Hz 175.4 Hz Highest pitch (Hz) — 462.96 Hz 830. 61 Hz
Maximum pitch range
(octaves) ≥2 1.4 2.24
Softest phonation (dB) — 63.6 dB 45.9 dB
Shout phonation (dB) — 90.6 dB 95.15 dB
Maximum loudness
range (dB) ≥40 27 dB 49.25 dB
Phonation Duration (sec) ≥14 26.6 seconds 42.02 seconds
Typical Speaking Voice
Airflow (L/s) 0.07–0.23 0.10 L/s 0.153 L/s Air pressure (cm H2O) ≤7.76 7.15 cm H2O 6.13 cm H2O dB/cm H2O ≥8.6 9.5 11.56 Loud Voice Airflow (L/s) 0.05–0.25 0.18 L/s 0.161 L/s Air pressure (cm H2O) ≤11.92 11.9 cm H2O 10.73 cm H2O dB/cm H2O ≥6.1 6.6 6.60
162 Voice Therapy: Clinical Case Studies
educated thoroughly regarding its use and her biofeedback target of funda- mental frequency. During the first 2 days of monitoring, the APM was not provid- ing biofeedback so a baseline could be acquired (days 1 and 2 in Figure 3–16). Biofeedback was provided only after the patient had reliably learned strategies during therapy that decreased vocal hyperfunction and increased pitch. This is because pitch modification indirectly targeted vocal hyperfunction; therefore, the obvious concern was that the patient could use hyperfunctional behaviors to increase pitch and maintain adequate compliance with the biofeedback and defeat the purpose of an ambulatory intervention. To assess the impact of the ambulatory feedback on the patient’s performance, the feedback was turned on and off for several days at a time while the APM continuously monitored vocal function to provide estimates of modal fundamental frequency.
Therapy Outcomes
Sixteen therapy sessions were completed. At the end of treatment, the patient expressed increased awareness of inef- ficient muscle patterns, the ability to alter tension progression, and improved capacity to speak without pain. Laryn- geal endoscopy with stroboscopy con- tinued to show good glottal closure and symmetric entrainment of vocal fold vibration and mucosal wave generation. There was also reduced supraglottal compression and an absence of asym- metric arytenoid abduction-adduction. Post-treatment results for auditory- perceptual assessment, acoustic and aero- dynamic assessment, and patient self- assessment are shown in Tables 3–11 through 3–13. Compared to pretreatment, there were post-treatment improvements in the CAPE-V–based judgments of overall severity of dysphonia, breathi- ness, strain, pitch, and loudness, but
FIguRE 3–16. Modal fundamental frequency values during 17 days of monitoring. Boxes indicate when ambulatory biofeedback was active. Mea sures for days 1 and 2 were obtained prior to the start of voice therapy to establish the patient’s baseline modal fundamental frequency.
Primary and Secondary Muscle Tension Dysphonia 163
only loudness was judged to be within normal limits (see Table 3–11).
The improvements in auditory- perceptual judgments of voice quality were reflected by post-treatment reduc- tions in acoustic perturbation (jitter and shimmer) and average sound pres- sure level with amplitude perturbation (shimmer) and average sound pressure level attaining normal values. Pitch and loudness ranges showed post-treat- ment increases to within normal limits. Modal pitch continued to be abnormally high following treatment which was expected based on the therapy goal to elevate the patient’s average speaking pitch to a level above the normal range. Post-treatment aerodynamic measures continued to be maintained within nor- mal limits (see Table 3–13).
All three scores (total score, physical functioning score, and social-emotional score) from the patient’s self-assessment of her vocal function (V-RQOL) showed significant post-treatment improve- ments indicating a positive impact of the voice therapy treatment on the patient’s daily function and quality of life (see Table 3–12).
Figure 3–16 shows the modal fun- damental values for each of the 17 days that the patient wore the APM. These results indicate that the patient main- tained a higher modal fundamental fre- quency when the feedback was turned on (red boxes) as opposed to when the feedback was turned off. This difference was statistically significant (t-test) at the p ≤ 0.03 level (Figure 3–17).
Summary and
Concluding Remarks
As stated at the beginning of this case report, the intent here was to dem-
onstrate the potential future role that ambulatory biofeedback may play in voice therapy. The main objective of using ambulatory biofeedback was to increase the patient’s ability to carry over therapy-induced vocal modifica- tions outside of the therapy session. Even though this patient showed clear post-treatment improvements in vocal function, it is not possible to assign the positive outcome to a particular part or parts of the therapy program, includ- ing ambulatory biofeedback, because several approaches were applied simul- taneously. In addition, there was no attempt to structure the application of the feedback to facilitate or demonstrate true leaning/retention of the targeted increase in modal speaking fundamental frequency. Better elucidation of the role of ambulatory biofeedback in voice ther- apy will require the formal appli cation
FIguRE 3–17. Overall averages of modal fundamental frequency at baseline, during biofeedback, and without biofeedback. The patient used a significantly higher modal fundamental frequency with biofeedback than without biofeedback (p < 0.03).
164 Voice Therapy: Clinical Case Studies
of principals based on motor learning theory (eg, varying feedback schedules, formal assessment of retention, etc).182
Falsetto voice, sometimes called puberphonia, has been described as a high-pitched voice quality consistent with adolescent males with biologically normal postadolescent vocal mecha- nisms. In the following case, Joe Stemple discusses the treatment of MTD second- ary to persistent use of falsetto voice in a 52-year-old female.
Case Study 20
Joseph C. Stemple
Use of Glottal Attack in the Treatment of Primary MTD in an Adult Female Presenting With Persistent Falsetto
History
Functional falsetto is associated most often with the postpubescent male. This author, however, has treated sev- eral adult women with this disorder. In the most recent case, patient CC was a 52-year-old, third-grade teacher who was referred by a friend with the complaint of having a “weak voice.” The weakness was something that she had noticed all her life, but she never thought that it could be modified.
Stroboscopic examination of her vocal folds revealed normal-appearing folds that approximated in a near-par- allel relationship. Glottic closure was