VOICE THERAPY

Adductor spasmodic dys a case for speech and lan

Sue Addlestone achieves good results with an approach that takes into account both the physical factors and emotional needs of people with adductor spasmodic dysphonia. Here, with her client Matt, she presents a robust response to Kendrea Focht and Paula Leslies conclusion in our Spring 09 issue that speech and language therapists should offer Botox in such cases.
READ THIS IF YOU WANT TO OFFER AN ALTERNATIVE TO MEDICAL INTERVENTION USE A HOLISTIC APPROACH WORK IN PARTNERSHIP WITH CLIENTS

dductor spasmodic dysphonia is a dystonia of the larynx which leads to abnormal patterns of phonation. Clients typically present with a voice which alternates between being intermittently extremely strained, and then completely normal, due to involuntary over-adduction of the vocal cords. It sounds as though the speakers throat is being strangled and then released. The resultant abnormal voice quality is present at all times, unlike certain other dysphonias which may come and go dependent on the time of day, number of conversation partners, background noise and so on. The cause of adductor spasmodic dysphonia has never been fully explained and there remains much debate as to whether the aetiology is neurological and / or emotional. In the Spring 09 issue, the conclusion of This House Believes (Focht & Leslie, 2009, p.21), was that Botox is currently considered the gold standard for treatment of adductor spasmodic dysphonia. The recommendation is that Botox be offered as the primary treatment for adductor spasmodic dysphonia, but what of speech and language therapy intervention in the management of this condition? I work as Clinical Lead in Voice at North Manchester General Hospital, which serves a population of 3.2 million. The number of clients presenting with adductor spasmodic dysphonia is small relative to my overall caseload. We do not have an ENT consultant on site who specialises in Botox, although there is a specialist locally who does. The ENT consultants at my hospital tend to approach adductor spasmodic dysphonia by prescribing drugs if they feel this is appropriate; for example, anti-reflux medication if there is an indication of gastro-oesophageal reflux disease (commonly referred to as GORD) or by

trying a short course of diazepam as a muscle relaxant. But, in the main, they refer these patients for voice therapy. My experience of managing clients with adductor spasmodic dysphonia leads me to reject the use of Botox. This is because I achieve successful outcomes through direct voice therapy combined with psychological therapy. I have based my therapy approach around literature and studies (for example, Anari et al., 2007; Cannito et al., 1994; Heaver, 1959; Zung, 1967). Cannito (1991) compared eighteen clients with adductor spasmodic dysphonia (ASD) to controls and found that over half of those with the condition had significantly impaired performance on psychometric measures of depression and anxiety (p.322). He recommended that from a clinical standpoint, [it] is critical that emotional disorders in ASD patients are identified (p.323). Shapir (1995) states that if the diagnosis of ASD is based on l-r, Ashleigh, Sam and Emma symptoms alone, patients[are] subjected to undue medical treatment (p.275). In treating people with adductor spasmodic dysphonia, speech and language therapists must therefore focus not only the clients voice, but also on the emotional component, as illustrated by one of my clients.

Matt

Matt is a 39 year old mental health nurse consultant. He was referred to me with a diagnosis of gastro-oesophageal reflux disease and adductor spasmodic dysphonia. The ENT consultant had previously treated Matt for GORD and had seen him for review on two occasions, with no improvement in the dysphonia. When Matt first presented in clinic, it took him 75 seconds to read the first two paragraphs of Arthur the Rat (author unknown)

compared to 34 seconds after therapy. The fact that it took Matt over twice as long to read the passage at initial assessment is due to the effect that adductor spasmodic dysphonia has on breath support. The condition leads to intermittent occlusion/restriction of airflow, which makes speaking slow and effortful. I carried out a perceptual analysis of Matts dysphonia using the GRABS scale (Hirano, 1981), where voice quality is evaluated using the parameters of Grade (overall voice quality), Roughness, weakness (Asthenicity), Breathiness and Strain (0 = normal, 1 = mild, 2 = moderate, 3 = severe). Matt obtained a score of 11 out of a possible maximum of 15. On a selfevaluation form made up of questions relating to functional, physical and emotional domains (see Deary et al., 1999), Matt scored 47 out of a maximum possible 60. This gave his vocal disability a classification of severe (where mild is less than 20, moderate is 2140 and severe is more than 41). Matts report of his voice disability indicated that, although it took a great deal of effort to speak, colleagues and his own patients were used to his voice, and he had not needed to make alterations at his place of work. In fact since the onset of the dysphonia, his job role had improved and he had gained an award for outstanding service to his profession. Family and friends had also adapted to his way of speaking. However Matt was keenly aware that his voice problem was becoming progressively worse. He had also become disillusioned by the lack of improvement: My voice had progressed from an initial hoarseness..to something far more debilitating. It had reached the point where it had become impossible to complete more than a few words.I became intensely conscious that I had no control over the sound that would come out of my mouth.

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VOICE THERAPY

sphonia: nguage therapy

I attended weekly appointments which initially focused on specific vocal exercises. With practice, it soon became apparent that I could perform these with some success at both the therapy sessions and in private, but I could not maintain this in general conversation. The target of therapy changed to incorporate psychological interventions. Through this, I became aware that, in the build up to the onset of my dysphonia and in the months following the symptoms, I had been subjected to several life stressors. It was through exploring these, in conjunction with voice therapy, that I became aware that, while I found vocalising difficult, my own anxieties and emotions were significantly exacerbating the problem. Increasingly I [had begun] to isolate myself professionally and socially. The psychological interventions I used with Matt consisted of a combination of different therapies. I have gained skills and experience in these areas mainly through self-directed learning, but also through attending training courses. I often use a combination of these practices when working with clients with dysphonia and also dysfluency. In Matts case, I used person-centred counselling techniques, Cognitive Behavioural Therapy (Butcher et al., 2007) and also incorporated the timeline from Draw on your emotions (Sunderland & Engleheart, 1993). This approach to treatment led Matt to report that: within a very short space of time I found there were increasing periods where my voice was clear. After four weeks I attended a social event where my voice was even worse than it had been for the preceding weeks and I found this to be a particularly frustrating experience. However the next day I found that my voice had virtually returned to normal. My final session involved improving the pitch of my voice and work around my view of the future..I now have complete control overmy vocal cords.I am confident in my ability to identify my condition at an early stage and modify my behaviour.

Sue and Matt, photo by www.karenwrightphoto.co.uk It is recommended that, when taking a voice history, clinicians should fully appreciate the (clients) psychological history (Butcher et al., 2007, p.8). If this is not done, the speech and language therapist will fail to deliver the appropriate form of therapy (p.8). In spite of Matts experience in the field of mental health, during the entire case history process he was at a loss to pinpoint any life events which he felt were significant enough to precipitate his dysphonia. I planned Matts therapy based on the information I had collected at his initial interview, beginning with direct voice exercises. However, I was mindful that adductor spasmodic dysphonia often fits the model developed by Butcher et al. (2007, p.25) as a Type 1 conversion voice disorder: Typically the patient will be resistant to exploring a psychological cause for the voice disorder (and)will not complain of anxiety and depression (despite)having a significant dysphonia. Had I based my therapy purely on what Matt told me at initial interviews, I would not have addressed the emotional side of Matts adductor spasmodic dysphonia. It was only when I began combining direct voice therapy with psychological therapy that a successful outcome was achieved. Prior to using psychological approaches, Matt made virtually no progress with voice exercises:

Back in control

I saw Matt for six sessions of therapy over a period of three months. At his final appointment I arranged to monitor his progress by phone at fortnightly intervals. After the second call Matt reported feeling back in control of his voice, and we agreed on discharge. By treating people with adductor spasmodic dysphonia exclusively with direct voice

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2010

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therapy, clinicians can fail to address the emotional issues which are symptomatic of the impaired performance on psychometric measures of depression and anxiety discovered by Cannito (1991, p.322). As a result, such clients fail to make any progress. The medics may then recommend Botox, which is not without its problems (Focht & Leslie, 2009). The evidence of the value of a combined therapy approach is summed up by Matt: Everyone loses their voice at some time in their lives but this is usually for a few hours a day. To lose your ability to speak removes something distinctly human from your make-up. I am walking and talking proof that a blanket ENT approach isnt going to work, as I actually deteriorated during my ENT treatment phase. Voice therapy has not just given me back the ability to speak - it has given me back SLTP my life. Sue Addlestone is Clinical Lead in Voice at North Manchester General Hospital, Clinical Lead in Dysfluency (Adults) at Stepping Hill Hospital and Clinical Lead in Dysfluency (Paediatric) at Manchester PCT. She is Associate Lecturer in Voice at Manchester Metropolitan University. You can contact Sue by e-mail, addle12@gmail.com. Acknowledgement Sincere thanks to Matt for his contribution to this article. His time, dedication and commitment in helping to offer an alternative to other sufferers has been invaluable.
References Anari, S., Carding, P., Hawthorne, M., Deakin, J. & Drinnan, M. (2007) Nonpharmacological effects of botulinum toxin on the life quality of patients with spasmodic dysphonia, Laryngoscope 117, pp.1888-1892. Butcher, P., Elias, A. & Cavalli, L. (2007) Understanding and treating psychogenic voice disorders: A CBT Framework. London: John Wiley and sons Ltd. Cannito, M. (1991) Emotional considerations in spasmodic dysphonia: psychometric quantification, Journal of Communication Disorders 24, pp.313-329. Cannito, M., Murray, T. & Woodson, G. (1994) Spasmodic dysphonia, emotional states and Botulinum Toxin treatment, Arch Otolaryngolgoy Head and Neck Surgery 120, pp.310-316. Deary, I., Webb, A., MacKenzie, K., Wilson, J. & Carding, P. (1999) Short, self-report voice symptom scales: Psychometric characteristics of the Voice Handicap Index-10 and the Vocal performance questionnaire, Journal of Voice 13, pp.557-569. Focht, K. & Leslie, P. (2009) This House Believes in Botox, Speech & Language Therapy in Practice Spring, pp.20-21. Heaver, L. (1959) Spastic dysphonia II: Psychiatric considerations, Logos 2, pp.15-24. Hirano, M. (1981) Clinical examination of voice, in Arnold, G.E., Winckle, F. & Wyke, B.D. (eds) Disorders of Human Communication. New York: Springer. Shapir, S. (1995) Psychogenic spasmodic dysphonia: a case study with expert opinions, Journal of Voice 9 (3), pp.270-281. Sunderland, M. & Engleheart, P. (1993) Draw on your emotions. Bicester: Winslow Press. Zung, W. (1967) Factors influencing the self rating depression scale, Arch Gen Psych 16, pp.543-547. Resource Arthur the Rat is a standard passage, origin unknown, with the original purpose of sampling all the phonemes in American English. It is freely available on the internet, for example at http://everything2.com/user/Sylvar/writeups/ Arthur+the+Rat.

REFLECTIONS DO I KEEP UPDATED THROUGH READING, ATTENDING COURSES AND APPLYING SKILLS IN PRACTICE? DO I UNDERSTAND THE POTENTIAL CONTRIBUTION OF LIFE STRESSORS TO ILL HEALTH? DO I APPRECIATE THAT CLIENTS MAY NEED HELP WITH SELFAWARENESS, WHATEVER THEIR PROFESSIONAL EXPERTISE?
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