May 26, 2009 Feature

Voice Boot Camp

Intensive Treatment Success

For patients with voice and airway disorders, speech-language pathologists traditionally provide weekly or biweekly treatment. For patients who cannot adhere to that schedule or for whom traditional treatment has proven unsuccessful, however, a different protocol may produce better results. In the voice and swallowing clinics at the University of Wisconsin-Madison, Division of Otolaryngology–Head and Neck Surgery, we have found success with an intensive voice treatment approach. Our "Voice Boot Camp" is designed for patients who have been resistant to other treatments or who live considerable distances from the clinic and for whom traditional treatment is impossible.

The voice and swallowing clinic is a large, multidisciplinary tertiary care center that provides treatment to individuals of all ages with voice and swallowing disorders. The multidisciplinary team includes more than 15 SLPs and singing-voice specialists, laryngologists, gastroenterologists, neurologists, and psychologists.

In our intensive treatment model, multiple SLPs—using a variety of techniques and approaches based on the patient's needs—treat patients with voice and airway disorders for four to six hours daily for one to seven days. There is precedent in the speech and language/voice literature for extended-duration therapy for functional dysphonia (Roy &Leeper, 1993) and hypokineticdysarthria/Parkinson's disease (Ramig, Sapir, Fox, & Countryman, 2001). The implementation of high-effort, intensive voice treatment is based on evidence of overload and intensity from clinical practices in neurology and physical therapy (Saxon & Schneider, 1995). This treatment follows theories of motor learning (Dishman et al., 2006), and facilitates motivation and dedication to treatment and transfer of learned skills, thus improving success with home practice and carryover. It is not surprising, therefore, to find success in treatment of dysphonias with an intensive treatment model.

Need for New Approach

We developed the intensive approach originally for patients who were seeking to benefit from dysphonia treatment but who lived far from the clinic and thus could not enroll in traditional treatment. We asked these patients to return to Madison for up to a week and to visit the clinic daily for treatment. Based on the patient's case history, physical laryngological exam, laryngeal imaging, acoustic and aerodynamic analysis, voice handicap and reflux indices, the teamed developed an individual treatment program that was carried out by at least three clinicians.

Two important factors led to the Boot Camp approach: We reasoned that multiple clinicians would improve carryover, and we believed that patients who agree to spend a week in treatment would have the high motivation and compliance necessary for successful treatment. Treatment success was determined by patient satisfaction, improved voice quality, improved closure pattern, and improved acoustic and aerodynamic measures.

Success with our initial group led us to apply the model to other patients, including those with recalcitrant long-term dysphonia who have plateaued with voice treatment, individuals with a limited window of availability (e.g., public speakers or performers with upcoming heavy vocal requirements) and individuals with unclear diagnoses.

Teamwork and Other Logistics

Because of the complexity of the Boot Camp approach (multiple clinicians, variety of techniques, scheduling additional assessments with other disciplines as needed), our program requires logistic organization. Each Boot Camp patient has a team leader, typically the clinician who will or who has performed the initial evaluation. The team leader is responsible for ensuring insurance pre-approval, arranging the schedule with other clinicians, conducting pre- and post-treatment evaluation, and facilitating daily communication among the team members.

Active team communication is essential to ensure consistency and facilitate integration between sessions, both of which help the patient in carryover of skills from session to session and, as needed, revision of goals and treatment methods. Active clinician communication works somewhat like a relay team. Clinicians keep logs detailing information about success/failures of each treatment session and recommendations for subsequent sessions; this log is passed on, along with the patient, at the end of each hour of treatment. The team meets for a post-treatment meeting at the end of each day. Patients are invited to attend some of these meetings to enhance their education about the voice disorder and its remediation.

Benefits

The multiple-clinician, intensive approach appears to yield several benefits: increased patient confidence in the ability to affect change; voice improvements in a short period of time; multiple perspectives from several clinicians and specialists in decision-making for complex patients; and patients' enhanced knowledge of tasks for home practice. In addition, the format has been beneficial in identifying the need for further diagnostic work with other professionals (e.g., laryngeal electromyography, psychological counseling, swallowing evaluation) as well as in solidifying the client's kinesthetic awareness. We have observed that improved kinesthetic feedback provides Boot Camp patients with better self-efficacy and confidence and enhances the patient's ability to improve and carry over treatment tasks to daily living.

In a group session at the termination of the program, the patient has the opportunity to ask questions and the team generates a follow-up plan, which may include six-week post-treatment diagnostic exam, referral for additional treatment to a local clinician, surgery, telepractice treatment, or a combination of options.

Susan L Thibeault, PhD, CCC-SLP, is assistant professor in the Division of Otolaryngology-Head and Neck Surgery, and director of the voice and swallow clinics at the University of Wisconsin-Madison. Contact her at thibeaul@surgery.wisc.edu.

Sherri K Zelazny, MA, CCC-SLP, is a senior speech-language pathologist in the voice and swallow clinics at the University of Wisconsin-Madison.

Stacy Cohen, MA, CCC-SLP, is a senior speech-language pathologist in the voice and swallow clinics at the University of Wisconsin-Madison.

cite as: Thibeault, S. L. , Zelazny, S. K.  & Cohen, S. (2009, May 26). Voice Boot Camp : Intensive Treatment Success. The ASHA Leader.

Boot Camp Case Studies

The following case studies—a breathing disorder and a voice disorder, both recalcitrant to treatment—illustrate how the voice Boot Camp functions.

Paradoxical Vocal Fold Motion

A 29-year-old medical resident in family practice, diagnosed with paradoxical vocal fold motion (PVFM) at 14 years of age and subsequently with asthma and gastroesophageal reflux disease, was referred to our clinic with PVFM recurrence following five symptom-free years. Her recurrence coincided with medical school graduation and the beginning of residency. Patient presented with inhalation phonation on every inhale during resting breathing and at natural pauses while speaking. After initial diagnosis, the patient had received behavioral therapy and medical evaluation and treatment, including heliox therapy, two supraglottoplasties, neurology evaluation (negative), Botox® therapy (unsuccessful) and asthma and reflux management.

Treatment consisted of 17 hours of direct treatment with three SLPs over two and a half days. Goals included elimination of inspiratory noise, achievement of carryover and generalization, and return to regular physical exercise. Treatment included training of the nasal abduction breathing exercise, attention to neck and shoulder tension, facial relaxation, abdominal breathing, frequent positive reinforcement, patient self-awareness, carryover in variety of settings, and activity-based breathing.

The patient achieved all goals with 100% accuracy within the treatment time. E-mail follow-up occurred at one, two, and six months post-treatment. The patient reported two occasions of symptom return but was able to perform exercises successfully for full resolution of PVFM. She was able to participate in all previous activities of daily living, including medical residency, social activity, and regular weekly running on the treadmill. She said her life was "back to normal."

Vocal Fatigue and Pain

A 53-year-old man from out of state came to our clinic after 18 years of hoarseness, vocal fatigue, and throat pain. Previous diagnoses included laryngopharyngeal reflux, superior laryngeal nerve paresis, Herpes zoster, autoimmune disease, allergies, vocal fold cyst, and scarring. His medical history included 13 procedures, including Nissenfundoplication, bilateral medializationthyroplasty and revisions, fat injections, and Cymetra injections. Six weeks of voice treatment had yielded no benefit. Surgical treatments provided some temporary voice relief but none helped the vocal fatigue and discomfort. We evaluated him and diagnosed multi-factorial voice disorder including suspected scarring and muscle tension dysphonia.

He participated in 18 sessions of behavioral treatment over a week, with focus on vocal hygiene, relaxation, muscle strengthening, vocal endurance and control, change in tone to be more resonant and forward, carryover, and vocal fatigue recovery. Infectious disease specialists and neurologists found strong antibody presence for aricella zoster and Epstein-Barr viruses. Laryngeal EMG revealed normal superior laryngeal nerve function bilaterally. By the end of the week, he was able to perform resonant voice exercises and vocal function exercises independently with 100% accuracy. He also maintained moderately resonant voice with approximately 90% accuracy during structured conversation and 75%–80% accuracy in free conversation. He reported reduced vocal fatigue and improved control of recovery techniques when he experienced problems related to vocal endurance. He underwent subsequent telepractice sessions and has maintained his progress two years post-treatment.



References

Dishman, R.K., Berthoud, H.R., Booth, F.W., Cotman, C.W., Edgerton, V.R., Fleshner, M.R., et al. (2006). Neurobiology of exercise. Obesity, 14(3), 345–356.

Ramig, L.O., Sapir, S., Fox, C., & Countryman, S. (2001). Changes in vocal loudness following intensive voice treatment (LSVT) in individuals with Parkinson's disease: A comparison with untreated patients and normal age matched controls. Movement Disorders, 16(1), 79–83.

Roy, N., &Leeper, H.A. (1993). Effects of the manual laryngeal musculoskeletal tension reduction technique as a treatment for functional voice disorders: Perceptual and acoustic measures. Journal of Voice, 7(3), 242–249.

Saxon, K., & Schneider, C.M. (1995).Voice exercise physiology. San Diego, CA: Singular Publishing Group, Inc.



  

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