or Broca's area, which is the portion of the brain controlling the muscles of speech (Taylor, 1989). Persons suffering from expressive aphasia tend to lack normal.
The Effect of Vocal Instruction and Vi-Pitch™ Feedback on the Speech of Persons with Neurogenic Communication Disorders: Two Case Studies NICKI
S. COHEN
Texas Woman’s
Denton
effects of a CVA can be devastating, since the resulting phys ical ramifications usually are accompanied by social, emotion al, and cognitive deficits. In addition, a patient often will ex
ABSTRACT: The purpose of this study was to examine the effect of vocal instruction and Visi-Pitch™ feedback on the speaking funda mental frequency range, vocal intensity, percentage of pause time and verbal intelligibility of two subjects with neurogenic communi cation disorders. Both subjects had suffered cerebrovascular acci dents and had been diagnosed with aphasia and dysarthria. The re search consisted of two single case designs, with the subjects acting as their own controls. The subjects’ vocal intensity, fundamental fre quency range, and percentage of pause time were measured by feed ing live speech samples into the Visi-Pitch™ weekly. Verbal intelli gibility was measured by recording pretest and posttest samples of the subjects’ speech and playing them for a panel of judges. The treatment sessions lasted for a period of ten weeks, one hour per week, and followed a progressive series of breathing and vocal ex ercises. The speech content of these exercises was based on a hier archical system of simple to complex speech tasks. The melodic ac companiment, which was played on a Kawai electric keyboard, con sisted of diatonic patterns of descending or ascending pitches that slightly exaggerated the prosody of normal speech. The treatment consisted of ten minutes of breathing instruction, thirty minutes of vocal exercises, and ten minutes of song singing. Data analysis revealed that Subject One experienced a 38% improvement in his percentage of pause time and an 8 dB increase in vocal intensity. No substantial changes were noted in his speaking fundamental frequency range or verbal intelligibility scores. Subject Two experienced a 32% reduction in pause time, a 9 dB increase in vocal intensity, and an 11% increase in verbal intelligibility. No substantial changes were noted in her speaking fundamental frequency range. The author recommended future research using a larger subject sample and separating the VisiPitch@ from the singing instruction treatment.
perience
difficulties
when
attempting
to communicate
with
others. Three major types of neurogenic communication disorders resulting from a CVA are aphasia, apraxia, and dysarthria. Ex pressive aphasia is characterized by impaired speech produc tion, especially in the area of fluency, or the length of inter pausal word runs (Gleason & Goodglass, 1984). It is caused by injuries to the anterior, or Broca’s area, which is the portion of the brain controlling the muscles of speech (Taylor, 1989). Persons suffering from expressive aphasia tend to lack normal speech prosody and experience difficulties when attempting to initiate sentences or combine words into phrases (Gleason & Goodglass, 1984). Apraxia, a disorder of the motor memory for speech articulation (Johnson, 1980), is caused by cortical damage to the areas of the brain that control motor program ming; specifically, the retro-central region (Luria, 1963). In dividuals with apraxia know what they want to say, but can not get their
speech
oral musculature
is characterized
lation
errors
and
motor
speech disorder
to produce
by multiple
inaccurate
word
it correctly.
Apraxic
and inconsistent imitations.
articu
Dysarthria
is a
from damage to the neural mechanisms that regulate speech movements (McNeil, Ro senbek, & Aronson, 1984) and refers to disturbances of res piration, phonation, and pitch (Darley, Aronson, & Brown, 1975). Dysarthric speech is characterized by limited verbal intelligibility, vocal intensity, and vocal range, as well as ab normal speech rates. In an attempt to enhance the expressive potential of persons
When employed in a rehabilitation setting, music therapists often are called upon to work with patients who have suffered from cerebrovascular accidents. Cerebrovascular accidents, or CVAs, result from the sudden interruption of blood flow through the internal carotid and vertebral arteries, the major vessels which supply blood to the brain and irrigate the cor tical and subcortical structures. Kolb and Whishaw (1985) de scribe four categories of cerebral accidents: encephalomala cias, cerebral hemmorrhages, angiomas, and aneurysms. The
with
neurogenic
trics Corporation
resulting
communication developed
disorders, an instrument
the
Kay Eleme
in 1977 called
the
Visi-Pitch™, which was designed to provide immediate visual biofeedback and statistical analysis of speech/voice charac teristics (LeBlance, Steckol, & Cooper, 1991). This instrument is akin to an oscilloscope; it contains a software program which extracts the fundamental frequency and amplitude features of speech signals, and displays them on a color monitor. As pects of the live speech signal, such as the subject’s speaking fundamental frequency, speaking fundamental frequency range, intensity, and percentage of pause time, can be pre sented in either graphic or numerical form on the computer screen.
Nicki S. Cohen, Ph.D., RMT-BC is Assistant Professor of Music Therapy and Voice at Texas Woman’s University, Denton. The author would like to extend her sincerest appreciation to Dr. Jean Ford for her wisdom and support and to the two clients of Aphasia Center who made this research possible. © 1995, by the National Association for Music Therapy, Inc.
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University,
Visi-Pitch
Feedback
71
The Visi-Pitch was designed to operate both as a diagnostic and treatment tool. In one study, it was used to assess the intonational contours of preschoolers’ imitative speech (Loeb & Allen, 1993). In a separate article, the Visi-Pitch™ was rec ommended as an educational tool for foreign students at tempting to learn English as a second language (Albertson, 1979). Because of its dual functions and sophisticated bio feedback capabilities, the Visi-Pitch™ often is used to promote expressive communication.
plication
of vocal instruction and Visi-Pitch™ feedback? in the speaking fundamental fre quency range of persons with neurogenic communication disorders after the application of vocal instruction and Visi-Pitch™ feedback? 4. What is the difference in the verbal intelligibility of per sons with neurogenic communication disorders after the application of vocal instruction and Visi-Pitch™ feedback?
3. What is the difference
Methodology Subject Selection
The Visi-Pitch was designed to operate both as a diagnostic and treatment tool. Singing also has been recommended as a therapeutic ap proach for persons with neurogenic disorders (Borchgrevink, 1982; Gardner, 1982; Hurwitz, 1971; Lucia, 1987; Mesalam, 1988) and specifically for persons with Broca’s aphasia (Benton, 1977; Gardner, 1983; Gleason & Goodglass, 1984; Keenan, 1987; Sparks, Helm, & Albert, 1974; Yamadori, Osumi, Ma suhari, & Okubo, 1977). The elements of correct singing, such as proper breathing techniques, coordinated phonation, and accurate diction, are essential for correct speech production as well. Numerous articles have emphasized the inclusion of practice songs (Darrow & Starmer, 1986; Klinger & Peter, 1953; Lucia, 1987; Michel & May, 1974; Ogden, 1982); breathing exercises (Bellaire, Yorkston, & Beukelman, 1986; Loven, 1957); and vocal exercises (Darrow & Starmer, 1986; Harbert, 1954; Loven, 1957; Lucia, 1987; Rogers & Fleming, 1981) in the speech rehabilitation of persons with neurological impairments. Gillis (1977) used instructed singing to help remediate the apraxia of speech in two children. The study revealed no significant differences in imitative speech, but significant improvements in the subjects’ spontaneous speech were noted. In recent studies, subjects with neurogenic communication disorders experienced improvements in speaking fundamental fre quency variability (Cohen, 1992), verbal intelligibility (Cohen, 1992; Cohen & Masse, 1993) and rate of speech (Cohen, 1988; Cohen & Masse, 1993) as a result of systematic vocal instruc tion.
The subjects were both clients with neurological impair ments who attended the Aphasia Center at the Parkland Cam pus of Texas Woman’s University. Both subjects met the fol lowing selection criteria: (a) they had suffered cerebrovascular accidents;(b) they had been diagnosed with expressiveaphasia by a speech-language pathologist using the Boston Diagnostic Aphasia Examination (Goodglass & Kaplan, 1983); (c) they had been diagnosed with dysarthria by a speech-language pa thologist; (d) they were both native speakers of English.
Procedure The research consisted of two single case designs, with the subjects acting as their own controls. In the pretest session, each subject was asked to read a paragraph that contained a variety of phoneme combinations. An audiotape was recorded of the pretest task. Data on the subjects’ vocal intensity, per centage of pause time, and speaking fundamental frequency range were collected by feeding live speech samples into the Visi-Pitch™. Data on the subject’s verbal intelligibility was col lected through recorded speech samples. Following the com pletion of the study, the posttest data were collected in an identical fashion. The treatment sessions took place at the Aphasia Center over a period of eleven weeks, one hour per week, and con sisted of a series of breathing and vocal exercises. Both clients met together with the researcher in a small therapy room which contained the Visi-Pitch™ and a Kawai electric key board. The Visi-Pitch™ was used to give the clients immediate visual and statistical feedback of their live vocal output on a computer
Research
Objectives
The purpose of this study was to examine the effect of vocal instruction and Visi-Pitch™ feedback on the rate of speech, vocal intensity, speaking fundamental frequency variability and verbal intelligibility of two subjects with neurogenic com munication disorders. The following research questions were asked: 1. What is the difference in the percentage of pause time of persons with neurogenic communication disorders af ter the application of vocal instruction and Visi-Pitch™ feedback? 2. What is the difference in the vocal intensity of persons with neurogenic communication disorders after the ap-
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screen
also printed
during
each session.
at each session
was used to accompany Each treatment session exercises to encourage
for future
The statistical analysis.
the vocal exercises
data were
The keyboard
and songs.
began with ten minutes of breathing the subjects to strengthen their
breathing mechanism and support their spoken sound. The subjects were encouraged to develop a kinesthetic sense of breathing during inhalation by feeling their back ribs expand against the backs of their chairs and by feeling their abdomens expand
against
their
placed
hands.
The
next
thirty
minutes
were dedicated to vocal exercises. The speech content of these exercises was based on a hierarchical system of simple to complex speech tasks and progressed from monosyllabic to polysyllabic
words
and from
three-syllable
to seven-syllable
Music Therapy
72
Subject
Table 1
Perspectives (1995), Vol. 13
One: Speaking
Intensity
Raw Data for Subjects’ Speaking Fundamental Frequency Range, Vocal Intensity, Percentage of Pause Time, and Verbal Intelligibility Measure ments Speaking Frequency Fundamental Range (Hz)
Session Number Subject One Pretest 2 3 4 5 6 7 8 9 10 Posttest
Intensity (dB)
Percentage of Pause Time
Percentage of Intelligi bility
129 94 95 96 99 89 85 87 97 100 98
36 40 43 44 43 42 39 40 42 41 38
51 41 23 20 20 23 23 26 18 13 19
63
524 419 467 533 511 480 492 637 453 542 553
37 38 44 40 41 46 40 41 43 42 44
55 59 41 28 27 21 35 31 30 23 27
20
0
4
6
Treatment
Figure 2.
8
10
i
12
Sessions
Subject one’s vocal intensity
in dB.
familiar to the subjects because of their previous involvement in a music therapy group. The researcher hypothesized that singing songs would encourage improved fluency and breath support for the subjects’ spoken speech. In the last ten min utes, the researcher obtained weekly probe samples by asking the subjects to speak two practice sentences into the VisiPitch™ computer. Both participants were given practice tapes to use at home which contained breathing and vocal exercises. They were also given notebooks containing all of their speech exercises, which they brought to each session. According to their family members, both subjects were diligent in their home practice.
58
Subject Two Pretest 2 3 4 5 6 7 8 9 10 Posttest
2
31
Data Collection sentences. The melodic accompaniment consisted of diatonic patterns of descending or ascending pitches which imitated the rhythm of the words and contained a range of pitches slightly larger than normal speech intonation. Each subject practiced singing or speaking at least one word and one sen tence into the Visi-Pitch™ every week. Following the vocal exercises, ten minutes were spent singing songs which were Subject One: Speaking
Frequency
The data for the subjects’ percentage of pause time, vocal intensity, and speaking fundamental frequency range were gathered weekly via the Visi-Pitch™ printouts. Verbal intelli gibility measurements were acquired by asking a panel of four judges to listen to the subjects’ pretest/posttest recordings and write down everything they understood. Verbal intelli gibility was computed by the average number of words the
Range
Subject One:
Percentage
of Pause Time
13Od
z ? E = $ : Le E z 1 .? IL
120 -
110 -
100 -
90 -
80 0
7 2
4 Treatment
Figure 1.
6
8
10
12
0
Sessions
Subject one’s speaking
2
4 Treatment
frequency
range in Hz.
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Figure 3.
6
8
10
Sessions
Subject one’s percentage
of pause time.
12
Visi-Pitch
Feedback
73
Subject One: Verbal Intelligibility
Subject Two: Vocal Intensity 48
1
Pretest POStteSt E Ii P a = z ;
0 E z 2 0.
60
E =
40
42 r” E 0 E
20
40
0 1
0
2
Figure 4. Subject one’s percentage of verbal intelligibility: and posttest data. judges perceived correctly divided by the total words in the paragraph. Following the completion the pretest, probe, and posttest samples were determine if any trends existed across time for four speech variables. Subject One: Background
2
4
6
8
10
f 12
Treatment Sessions
Pretest
Figure 6. Subject two’s vocal intensity in dB.
number of of the study, analyzed to each of the
and Results
Subject One was a 70-year-old man who had suffered a right cerebrovascular accident (CVA) two-and-a-half years pri or to the study and had been diagnosed with anomic aphasia with dysarthria. It is noteworthy to mention that this subject was left-handed, so his stroke produced the same speech deficits as a right-hand-dominant person with left hemispher ic damage. Subject One’s speech was characterized by im precise articulation and reduced volume. He also experienced word retrieval problems during conversational speech. The most noticeable improvement occurred in Subjects One’s speech rate, which decreased a total of 38% pause time over the ten-week treatment period. His vocal intensity also increased a total of 8 decibels. No substantial changes were noted in his speaking fundamental frequency range. Subject
One’s verbal intelligibility decreased slightly from 63% to 58% between the pretest and posttest sessions. Subject Two Subject Two was a 64-year-old woman who had suffered a left cerebrovascular accident one-and-a-half years prior to the study, and had been diagnosed with moderate aphasia, mod erate apraxia, severe dysarthria, and a right hemiparesis. Sub ject Two’s speech was halting, with imprecise articulation and reduced volume. Over the course of the ten-week treatment period, Subject Two experienced a 32% improvement in pause time. Her vocal intensity increased a total of 9 decibels. Like Subject One, she did not experience a difference in speaking fun damental frequency range. However, her verbal intelligibility improved from 20% to 31% between pretest and posttest sessions. Discussion The subjects in this study both experienced an improve ment in speech rate and vocal intensity after receiving vocal
Subject Two: Speaking Frequency Range A
Subject Two: Pause Time
1 60’
E F
50
f : 0. s b ; 8 k P
40 -
30 -
f 2
4
Treatment
Figure 5.
6
8
10
12
0
Sessions
Subject two’s speaking frequency
2
4
6
8
10
Treatment Sessions
range in Hz.
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Figure 7.
Subject two’s percentage
of pause time.
12
Music Therapy Perspectives (1995), Vol. 13
74 Subject Two: Verbal Intelligibility
Visi-Pitch™ treatment the efficacy of each.
from the singing treatment
to measure
REFERENCES
1
2
Figure 8. Subject two’s percentage of verbal intelligibility: and posttest data.
Pretest
instruction and Visi-Pitch™ feedback for ten weeks. In addi tion, Subject Two scored a substantial improvement in verbal intelligibility. Subject One experienced an improvement in 50% of the speech variables and Subject Two experienced an improvement in 75% of the speech variables. Based upon these results, it seems feasible that the combined approach of singing practice and Visi-Pitch™ feedback may help im prove the conversational speech of individuals with disabling communication disorders. In previous practice, the investigator of this study had ob served that clients with the sole diagnosis of expressive aphasia did not always benefit from music-assisted speech practice because of word production problems. However, clients with
During the course of the study, it was gratifying for the researcher to witness the subjects’ growing en thusiasm in the treatment sessions.
motor speech disorders, such as dysarthria, seemed to be more successful with this type of intervention. The subjects were selected for this study because they both had concom itant diagnoses of aphasia and dysarthria. During the course of the study, it was gratifying for the researcher to witness the subjects’ growing enthusiasm in the treatment sessions. They actively became involved in their treatment and made numerous comments about their sense of progress. Following the completion of the study, the re searcher met with the subjects and their families to discuss the results. All participants expressed their appreciation for the treatment. In the debriefing session, both subjectsstressed that it was the mutual inclusion of the Visi-Pitch™ and the singing instruction that enhanced their therapy sessions and provided them with an incentive for practicing at home. Based upon the success of these two case studies, a similar study is recommended using a larger subject pool and separating the
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Albertson, K. (1979). Teaching pronounciation with an oscilloscope. Journal of the National Association of Learning Laboratory Directors, 13, 25-30. Bellaire, K., Yorkston, K. M., & Beukelman, D. R. (1986). Modification of breathing patterning to increase naturalness of a mildly dysarthric speaker. Journal of Communication Disorders, 19, 271-280. Benton, A. L. (1977). The amusias. In M. Critchley and R. A. Henson (Eds.), Music and the brain (pp. 378-397). Springfield, IL: Charles C. Thomas. Borchgrevink, H. M. (1982). Prosody and musical rhythm are controlled by the speech hemisphere. In M. Clynes (Ed.), Music, mind, and brain (pp. 151 157). NY: Plenum Press. Cohen, N. (1988). The use of superimposed rhythm to decrease the rate of speech in a brain-damaged adolescent. journal of Music Therapy, 25, 85 93. Cohen, N. (1992). The effect of singing instruction of the speech production of neurologically imapired persons. Journal of Music Therapy, 29, 87-102. Cohen, N., & Masse, R. (1993). The application of singing and rhythmic in struction as a therapeutic intervention for persons with neurogenic com munication disorders. Journal of Music Therapy, 30 81-99. Darley, F., Aronson, A., & Brown, R. (1975). Motor speech disorders. London: W. B. Saunders Co. Darrow, A. A., & Starmer, G. J. (1986). The effect of vocal training on the intonation and rate of hearing impaired children’s speech: A pilot study. Journal of Music Therapy, 23, 194-201. Gardner, H. (1982). Artistry following damage to the human brain. In A. W. Ellis (Ed.), Normality and pathology in cognitive functions (pp. 299-323). NY: Academic Press. Gardner, H. (1983). Frames of mind. NY: Basic Books, 59-127. Gillis, B. A. (1977). Effects of musical approach to remediate speech on apraxia of speech in children. Unpublished master’s thesis, University of Colorado, Greely. Gleason, J. B., & Goodglass, H. (1984). Some neurological and linguistic ac companiments of the fluent and nonfluent aphasics. Topics in Language Disorders, 4, 71-81. Goodglass, H. & Kaplan, E. (1983). Boston diagnostic aphasia examination. Phil adelphia: Lea & Sebiger. Harbert, W. K. (1954). Music techniques applied in disordered speech: A case report by the music worker. Music Therapy, 3, 59-61. Hurwitz, L. J. (1971). The word: A neurologist’s view of aphasia. Gerentologia Clinica, 13, 307-319. Johnson, J. P. (1980). Nature and treatment of articulation disorders. Springfield, IL: Charles C. Thomas. Keenan, J. (1987). first aid for aphasia: Home exercises. Chicago: National Easter Seal Society. Klinger, H., & Peter, D. (1963). Techniques in group singing for aphasics. Music Therapy 1962, 12, 108-112. Kolb, B., & Whishaw, I. Q. (1985). Fundamentals of human neuropsychology (2nd ed.). New York: W. H. Freeman and Company. LeBlanc, G. R., Steckol, K. F., & Cooper, M. H. (1991). Advances in non-invasive measures of vocal acoustics. Ear, Nose and Throat Journal, 70 678-684. Loeb, D. F., & Allen, G. D. (1993). Preschoolers’ imitation of intonation con tours. Journal of Speech and f-fearing Research, 36, 4-13. Loven, M. A. (1957). Value of music therapy for mentally retarded children. Music Therapy 1956, 6, 165-171. Lucia, C. (1987). Toward developing a model of music therapy intervention in the rehabilitation of head trauma patients. Music Therapy Perspectives, 4, 34-39. Luria, A. R. (1963). Restoration of function after brain injury. NY: Macmillan Co. McNeil, M., Rosenbek, J., & Aronson, A. (1984). The dysarthrias. San Diego: College-Hill Press.
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Mesalem, L. (1988). The power of communication. Cognitive Rehabilitation, 6, 32-36. Michel, D. E., & May, N. H. (1974). The development of music therapy pro cedures with speech and language disorders. Journal of Music Therapy, 11, 74-80. Ogden, J. N. (1982). A study of the value of musical activities in articulation therapy. Unpublished master’s thesis, The University of Kansas, Lawrence. Rogers, G. P., & Fleming, P. (1981). Rhythm and music in speech therapy for the neurologically impaired. Music Therapy, 1, 33-38. Sparks, R. W., Helm, N., & Albert, M. (1974). Aphasia rehabilitation resulting from melodic intonation therapy. Cortex, 10, 313-316. Taylor, D. (1989). A neuroanatomical model for the use of music in the re mediation of aphasic disorders. In M. Lee (Ed.), Rehabilitation, music, and human well-being (pp. 168-178). St. Louis: MMB Music, Inc. Yamadori, A., Osumi, Y., Masuhari, S., & Okubo, M. (1977). Preservation of singing in Broca’s aphasia. Journal of Neurology, Neurosurgery and Psychiatry, 40, 221-224.
The Music Therapy Department within the Professional Education Division at Berklee College of Music seeks an Assistant Professor with a strong background in music therapy. The successful candidate will develop and teach courses in the music Other duties will include advising music therapy students, developing liaisons with community agen therapy concentration. cies, and supervising student practica. 3) at least three years of full-time clinical employ Candidates should possess 1) the RMT or CMT, 2) Board Certification, ment, 4) a minimum of a Master’s degree in Music Therapy or a closely related specialty, and 5) at least 12 semester hours of graduate music therapy course work. Doctorate, advanced training in music and medical technologies, research and publish ing experience are preferred. Berklee College of Music is a private four-year institution with an educational and professional career preparation in the field of contemporary music. Applicants arc requested receive full consideration.
submit a cover letter, a curriculum Starting date: September 1, 1996.
to
Please send material to: MT Search Committee Office of the Professional Education Berklee College of Music 1140 Boylston Street, Box 329 Boston, Massachusetts 02215-3693
Division
Berklee College of Music is an equal opportunity
employer,
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vitae
mission of providing
and four letters of reference
excellence
by February
in academic
1, 1996 to
