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.
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.