Journal of Voice
Vol. 5, No. 2, pp. 168-172 © 1991 Raven Press, Ltd., New York
Expanding Perspectives in Care of the Speaking Voice Daniel R. Boone Department of Speech and Hearing Sciences, University of Arizona, Tucson, Arizona, U.S.A.
Summary: The effective voice clinician has always had to borrow from various disciplines: voice science, otolaryngology, psychology, and speech-language pathology. Such eclecticism requires, however, that the clinician integrate the perspectives of these various disciplines into some kind of theoretical clinical bias. One bias might be that with greater use of instrumentation in voice therapy, the voice clinician must not substitute data collection for attending to the feelings of the patient. By using the clinical input from various disciplines, for example, voice clinicians might develop a useful clinical perspective that vocal hyperfunction is one of the primary causes of many voice disorders. Consequently, from such a clinical view might come a treatment perspective that can clearly define the problem (too much effort while speaking) and offer a rationale for voice remediation. Key Words: Voice therapy--Speaking voice-Therapy perspective---Vocal hyperfunction.
tation and monitor closely new instrumentation as it develops. A clinical management perspective can be fostered by appreciating the view of the otolaryngologist, whose primary bias is in the identification and treatment of diseases that may affect the voice. We must also develop a psychological perspective of people as people; we need to revisit the past and present literature in the areas of normal and abnormal psychology so that we can develop insights into personality, learning, and motivation. Finally, we must critique the results of voice therapy as reported by our clinical voice colleagues (although these therapy outcome data are rarely reported). Hopefully, our perspectives can lead us to develop a theoretical stance, a clinical philosophy that would be less vulnerable to the continuous assault of new untested beliefs and knowledge. On occasion, we have observed voice clinicians who have a b a n d o n e d their voice t h e r a p y m a n a g e m e n t approaches to a c c o m m o d a t e the newest instrumentation or therapy recommendation. Perhaps, once we have established some kind of theoretical voice management bias, we might be more discriminating in incorporating new management suggestions for
A n y o n e who has studied the literature on the care of the speaking voice over the past 30 years has seen a number of voice authorities come and go, and has witnessed a continuous emergence of new instrumentation. In contrast, there have not been many new, innovative therapy techniques for improving the speaking voice. Furthermore, it often appears that some voice clinicians seem to take the advice of each new authority or indiscriminately purchase and use new pieces of equipment, often appearing to lack a consistent management perspective. Developing management effectiveness requires a theoretical bias. Such a bias can often be created from integrating the observations and findings of our past and present professional colleagues. For example, we must have a good understanding of normal speaking mechanisms as a prelude to working with voice problems. We must be aware of the relative merits of past and present voice instrumenAddress correspondence and reprint requests to Dr. D. R. Boone at Department of Speech and Hearing Sciences, University of Arizona, Tucson, AZ 85721, U.S.A. Presented at the 19th Annual Symposium: Care of the Professional Voice, Philadelphia, PA, June 6, 1990.
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our voice patients. We would recognize the relative advantages of using (or rejecting) new ideas and methods. This article will look at the speaking voice from a few perspectives: scientific, instrumental, laryngological, and psychological. We will then borrow from these various viewpoints and offer a working perspective that may aid t h e clinician in providing care of the disordered speaking voice. A SCIENTIFIC PERSPECTIVE Although the study of the head and neck historically began with a focus on anatomical structure, early voice scientists were concerned with the dynamic aspects of how the vocal tract worked. This focus on voice physiology was hampered by extreme limitations in equipment, forcing early investigators to develop innovative methods for studying muscular activities within the larynx and tongue movements within the oral cavity (1,2). Much of our early knowledge of vocal mechanisms came from the static study of vocal tract organs as seen in detailed anatomical drawings (3,4) followed in later years by excellent contrast photographs (5,6). Much of the early speech science data were focused on measuring static behaviors. Because of instrument limitations, real-time data were not possible. Focus was given to the physics of sound followed by interest in such acoustic measures as frequency, formants, intensity, and velocity. Normative respiratory volume data were developed. Continued attention was given to fundamental frequency and optimum pitch, using such laborious measuring devices as the phonellograph and the early spectrograph. With refinements in electronic instrumentation, it became possible to look more at the dynamic and interactive movements of respiration, phonation, and resonance that contribute to the speaking and singing voice. Early use of stroboscopy (7) in the 1930s added the element of slowing down the vibratory wave, permitting a view of vocal fold vibration that neither the naked eye or physical measurement had previously identified. The early high-speed film of the larynx by Moore et al. (8) amazed its viewers with its visualization of complex laryngeal events. Then came the fiberoptic endoscope, where we were able to see the fantastic adjustments of the laryngeal and supraglottic vocal tract required for various phonatory acts. Then came computer-
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assisted devices that permitted real-time analyses of various acoustical and physiological behaviors. The presenting visual and acoustic data are now so complex that we may have difficulty applying them to our work. One thing is sure: as voice science has taken a new stance in measuring and studying the dynamic function of phonation, the scientific findings have far greater relevance to the clinical process than did the fixed, static data of yesteryear. AN INSTRUMENTAL PERSPECTIVE Instruments for measuring various aspects of the speaking voice have improved dramatically over the years. For example, to find fundamental frequency 40 years ago required hand counting of striations on the phonellogram or measuring the distance between harmonics on a spectrogram. Acoustic devices important for analyzing the speaking voice included audio recorders (disk, wire, and tape), oscilloscopes, the phonellograph, and the spectrograph. Measurements were generally confined to static performance, such as having the subject prolong a vowel. In Table 1, we see an alphabetical listing of various devices helpful for looking at some aspect of respiratory function. Early breathing instruments were spirometers, which provided some kind of volume data, and manometers, which gave pressure values. Pressure and flow have been more recently measured by using pressure transducers and the pneumotachometer or by using the commercially available Phonation Function Analyzer (9). More dynamic measures of muscles involved in respiration have been possible using electromyographic and magnetometer tracings. It is now possible to obtain realistic dynamic respiratory data that can give clinician and patient alike some feedback about the degree of synchrony between respiratory effort (or lack of it) and phonatory result. Table 2 shows an alphabetical listing of various instruments available for measuring some aspect of TABLE 1. Respiratory measurement instruments Electromyograph Magnetometers Manometers Phonation Function Analyzer Pneumotachometers Pressure transducers Spirometers Journal of Voice, Vol. 5, No. 2, 1991
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D. R. B O O N E TABLE 2. P h o n a t o r y m e a s u r e m e n t instruments Electromyograph Fiberoptic endoscope Fundamental Frequency Indicator Glottograph Laryngeal mirror Laryngoscope Phonation Function Analyzer Spectrograph Stroboscope Video recorders Visi-Pitch
D D S D D D S S D D S
D, provides a dynamic analysis; S, provides a more static analysis.
phonation. The more static measures are marked S; measures that are primarily dynamic measures that provide visual information about vocal tract physiology are marked D. The present popularity among clinicians of videoendoscopy and videostroboscopy is probably related to being able to visualize vocal tract physiology as it is happening (real-time observation). An effective example of looking at the physiologic changes of the vocal tract required to produce various voices was provided by Feder in 1984 (10). In the Feder video tape, we can witness the fantastic vocal tract adjustments required to produce different voices by the same voice impersonators (Mel Blanc and Rich Little), i.e., we can observe such hyperfunctional events as supraglottal closure of the larynx in the production of certain voices (such as the Roadrunner and George Burns). Clinical use of the nasoendoscope has revealed much supraglottal and pharyngeal muscle activity in production of some voices. A recent endoscopic study (11) looking at supraglottal postures in opera performers found that supraglottal constriction may well be the norm for such performance. Not until the endoscope was used as a regular part of voice therapy has the clinician been able to observe realtime vocal tract adjustments. The computer-assisted voice acoustic analyzer, like the Visi-Pitch (12) or the Phonation Function Analyzer (9), has made the measurement of fundamental frequency, habitual pitch, or jitter instantly available to the clinician. Also, these acoustic data can provide valuable feedback data to the patient when the equipment is used in voice therapy. Instruments for looking at various parameters of oral and nasal resonance are listed in Table 3. The pressure/flow and air volume instruments offer fixed or static measurements related to resonance. Similarly, relative oral-nasal acoustic data are provided by the Tonar II (13) and more recently by the Journal of Voice, Vol. 5, No. 2, 1991
Nasometer (14). Cinefluorography and nasoendoscopy provide ongoing visualization of the various components of the velopharyngeal (VP) closure mechanisms. Current instrumentation now allows us to correlate acoustic pressure/flow data with observed VP movements. The availability today of useful instrumentation that can yield both static and dynamic data about the speaking voice gives the present-day clinician a tremendous edge over his or her predecessor of a decade ago. A LARYNGOLOGIC PERSPECTIVE A laryngologic perspective is provided by the laryngologist in the care of the speaking voice. While many speaking voice problems are related to abuse and misuse of vocal mechanisms, many voice problems are the direct result of laryngeal disease. The laryngologist focuses on the integrity of the total airway from the bronchial system to the nares (with all the cavities and structures in between). The primary perspective of most laryngologists appears to be preservation of the airway and identification/treatment of vocal tract disease. Vocal integrity or voice improvement is often of secondary interest to some laryngologists. However, through the efforts of laryngologists specializing in the care of the professional singing and speaking voice (1518), there has been greater interest by the otolaryngologic community in working with problems of the singing and speaking voice. The speech-language pathologist's task in improving the speaking voice has to be secondary to such medical priorities as airway preservation related to problems of papilloma, laryngeal web, vocal cord paralysis, or laryngeal cancer. For many small, benign lesions like nodules or polyps, the laryngologist and speech-language pathologist should work together in making decisions specific to when surgery is necessary and when to use vocal rehabilitation or when to use both. The laryngologic TABLE 3. R e s o n a n c e m e a s u r e m e n t instruments Cinefluorography Manometers Nasoendoscopy Nasometer Pneumotachometer Pressure transducers Spectrograph Tonar II
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priority is for the physical preservation of the airway. Voice improvement can only be planned after the physical status of the larynx and total airway has been determined. A PSYCHOLOGICAL PERSPECTIVE The early training of speech pathologists was much more heavily steeped in psychology than it is today. The feelings and psychological needs of the patient received priority in management of the speaking voice. Paul Moses in his classic book, The Voice of Neurosis (19), wrote that many voice problems were but symptoms of an underlying interpersonal problem. A psychological point of view in care of the speaking voice is that the underlying psychological status of the patient may well dictate how he or she speaks. Speech-language pathologists like Greene (20), Murphy (21), and Aronson (22) have questioned the value of only working on voice symptoms. The symptomatic approach to voice therapy (2325) says that we can modify voice symptoms without probing into the psychological status of the patient. This symptomatic approach advocates that by curbing abuse-misuse of the speaking voice and by learning to use the voice in an easy, synchronous manner, we can develop a better voice. As an advocate of the symptomatic approach to voice therapy, I believe we need to appreciate and develop our psychological perspectives. Many people use a voice that reflects what they feel inside. Many of our voice patients are crying inside for us to recognize them first as people and perhaps secondarily as people with voice problems. Today in our evaluations, we may be so intent on completing our acoustic, airflow/pressure, glottogram, and stroboscopic examinations that we forget to ask the patient, " H o w are you feeling?" Attention to the psychological aspects of our examination might tell us that perhaps we need to rethink our priority for extensive instrumental measurement, particularly if it is done at the expense of seeing the patient as a person. A VOICE THERAPY PERSPECTIVE The voice clinician has always borrowed from various disciplines: voice science, otolaryngology, psychology, and speech-language pathology. It may be that an expanded ideology in the care of the speaking voice demands that we integrate a man-
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agement-treatment approach that embraces all four of these disciplines. The scientific perspective tells us that much of our decision-making for the voice patient should be based on normative information. Furthermore, it dictates that our norms be developed from both a static (a fixed vocal task) and a dynamic (a natural moving vocal task) point of view. With the relatively recent advent of dynamic instrumentation, such as the endoscope, glottograph, and stroboscope, the clinician is able to visualize the faulty physiology that is producing the altered voice. Using such instrumentation, the clinician appears able, for example, to differentiate the hyperfunctional voice from the normal voice (26). We can now, in our early management of the patient with a voice disorder, instrumentally observe what the patient is doing, provide the patient various therapy approaches, and see how such approaches modify the voice. We are able to judge objectively and subjectively by ear the effects of speaking in a different voice mode. The care of the speaking voice requires the close interaction of the laryngologist and the speechlanguage pathologist. Voice therapy should not begin without a medical evaluation of the larynx and the total airway. Instrumentation, such as videostroboscopy, has brought the two professions closely together as we study the normal and the disordered voice. In our voice therapy, we must return to greater patient orientation. In our quest for complete objective and behavioral analyses, we must not forget about the person behind the voice. We must relearn and use some of the basic tenets of motivational and personality theory to urge our patients toward wanting to improve their voices. We must recognize patient discouragement and fear and offer warm support when it is needed. We must not be afraid to be a friend. Perhaps the one clinical bias that has emerged over time with increasing validity is the need to recognize vocal hyperfunction (too much effort). In the majority of problems with the speaking voice, it would appear that the speaker is putting too much effort into the voicing task. Excessive vocal effort has been described from a number of recent videoendoscopic (27,28) and videostroboscopic (29,30) studies, supporting the observation that new instrumentation can serve us well clinically. The clinical literature needs further studies to validate the construct of vocal hyperfunction and outcome studies Journal of Voice, Vol. 5, No. 2, 1991
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to support the use of voice therapy as a method of treatment. CONCLUSION The voice clinician needs to develop some perspectives and allow these perspectives to guide in the management and treatment in the care of the speaking voice. Clinicians need to develop a treatment philosophy and stance that can withstand each new idea that comes along. The new ideas need to be integrated gradually into one's existing clinical beliefs. With a remarkably expanded literature, fostered in part by increased availability of useful instrumentation, the present-day clinician cannot only provide effective voice care but is in an excellent position to contribute to the data base of what is effective voice therapy.
10. 11.
12. 13. 14. 15. 16. 17. 18. 19. 20. 21.
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