Accent Method for Voice Therapy - Literature review Example

Introduction It was Svend Smith who originally developed the Accent method (AM) between the years 1935 and 1970 to improve speech (stuttering) and voice. AM can be considered as a holistic process to develop optimal voice and speed function. Rhythmic consonant sounds (called accents) are vocalized in combination with body movements with an emphasis on respiratory support for each accent. Various studies indicate a positive efficacy of AM, but a motivated patient and a skilled clinician are required. Rationale of Accent method AM involves the dynamic integration of abdomino-diaphragmatic breathing, accentuated rhythmic vowel play (phonation), articulation, as well as body and arm movements (Kotby, 1995). Since the method emphasizes timing, the rhythmic body movements may help the assembly and execution of new motor programs in the brain in a coordinated manner (Berry et al., 1995). In addition, the vocal fold posture (vocal folds that are barely touching or barely apart) that is trained in the method, maximizes voice output, while protecting the vocal folds from injury (Berry et al., 1995). Indications for AM include: a) Organic voice disorders- paralytic dysphonia, paralysis of vocal cords, phonatory hyperfunction, sulcus glottideus, dysphonia due to iatrogenic effect of hormonal therapy, acute vocal trauma, acute laryngitis in professional voice users; b) Nonorganic (functional) voice disorders-all subtypes of habitual nonorganic voice disorders, childhood hyperfunctional dysphonia, ventricular dysphonia, after voice return in cases of habitual aphonia, psychogenic voice disorders with bizarre vocal behavior; c) Minimal associated pathological lesions (MAPLs)-small soft vocal nodules in adults, contact granuloma, early Reinke’s edema;d) Vocal problems of professional voice users; e) Supplemental therapy-after phonosurgery, acute voice problems after radiotherapy etc; f)other indications-dysarthria, stuttering, prosody disorders (Kotby, 1995). Physiology and Method of Accent method The voice exercises are performed with the clinician and subject standing side-by-side, holding each other’s hands. The back of each other’s one hand rests on the stomach near the navel. Both breathe in the same rhythm and follow the trunk movements of each other (forwards during inspiration and backwards during phonation); thus, the movements are controlled kinaesthetically (Thyme-Frøkjaer & Frøkjaer-Jensen, 2001). Initially, the exercises are performed at a low pitch, breathy voice quality, gentle voice effort and with a close vowel articulation. Next, the clinician alternates between open and close vowels (Thyme-Frøkjaer & Frøkjaer-Jensen, 2001). The various exercises are conducted in different musical tempos (Largo, Andante, Allegro) with a hand drum, synchronous with specific soft-phonatory tasks to a particular vowel (Kruse, 2005). A musical inclination and high motivation of the patient are positive prognostic factors, while conditions like hearing impairment of the patient, impairs the success of the program. Other important contributing factors are the skill level, education and experience of the clinician (Kotby, 1995). Therapeutic Efficacy of AM Bassiouny, 1998, conducted a study to evaluate the efficacy of AM utilizing a controlled experimental model, based on the concept of group comparisons. Forty-two patients who presented with a variety of vocal pathologies (nonorganic (functional) dysphonia; MAP lesions; and vocal fold immobility) were distributed randomly into two groups: group 1 (G1) and group 2 (G2). Group 1 (G1) was given voice hygiene advice plus the accent exercises, while group 2 (G2) was given only voice hygiene advice. Elementary diagnostic procedures and clinical diagnostic aids like laryngo-video-stroboscopy, and high fidelity voice recording were performed. Additional instrumental measures included aerodynamic measures, acoustic analysis, and inverse filtering measures. The difference in improvement between G1 and G2 at the end of the observation significantly favored G1. There were significant improvements in G1 in certain items specific for the various etiologic categories. Smith & Thyme (1976) studied the effect of a short-term (10 sessions) AM therapy course on the voice of 30 students. An acoustic analysis battery was used. The post-therapy measurements showed an increased intensity across the whole frequency spectrum, especially below 1000 HZ. The researchers concluded that AM was efficacious and that the increased energy below 1000 Hz may be responsible for the improvement in speech intelligibility and in giving the impression of a fuller voice. Thyme & Frøkjaer-Jensen, 1983, conducted a short, intensive voice therapy program (4 hours daily for 5 days) to 16 trained speech pathologists (logopedists). Instrumental assessment of voice was done pre and post treatment using on electroglottography (EGG) and phonetographic (Voice Range Profile-VRP) recordings. EGG showed a longer glottal closure. The VRPs showed an increase in the “phonatory area” (or voice field) by a total of 3.3 semitones. The upper notes were increased by 1.7 semitones, and the lower ones were lowered by 1.6 semitones. The maximum dynamic range was increased by 10.6 dB. Löfqvist, 1986, found that AM could increase the ratio of LTAS energy above 1000 Hz relative to the energy below 1000 Hz. Kotby et al., 1991, studied the efficacy of AM on 28 patients in treating three main etiological groups; nonorganic (functional) voice disorders, nodules, and vocal fold paralysis with persistent glottal gap. The diagnostic workup helped to give information on four main areas: patients own evaluation of the change in degree of symptoms, auditory perceptual assessment (APA) following a modified GRBAS scale, visual assessment and documentation using indirect-micro-laryngo-video-stroboscopy with measurements of the changes in size of lesion (nodule or glottal gap), and aerodynamic studies measuring several parameters. A positive grade shift in 25 out of 28 subjects was noted after a self-analysis by patients. Improvement in APA showed a positive grade shift in the overall grade in 19 cases, strained voice quality showed positive grade shift in 14 cases, leaky quality showed positive grade shift in 12 cases, breathy and irregular qualities did not show significant positive shifts. A reduction in the size of nodule was noted in all 6 cases and a reduction of glottal gap was noted in 4 out of 6 cases after an indirect-micro-laryngo-video-stroboscopy examination. A complete disappearance of glottal gap was seen in 2 cases of vocal fold paralysis. A significant improvement in maximum phonation time (MPT), mean flow rate (MFR), subglottal pressure, and glottal efficiency (GE) was observed with vital capacity (VC), phonatory quotient (PQ) and glottal resistance (GR) not showing significant positive change. From these observations, the authors concluded that AM is therapeutically effective in nonorganic (functional) voice disorders, vocal nodules, and paralysis of vocal cords, and recommended AM as the treatment of choice in cases of soft nodules with a base of Read More