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EMG biofeedback treatment of dysphonias and related voice disorders.

Abstract

This article reviews the development of EMG biofeedback as a tool for operant learning, including the development of surface EMG biofeedback and support for the use of such biofeedback for treating dysphonias and related voice disorders. A few, well controlled empirical investigations suggest that EMG biofeedback helps some individuals with dysphonias to gain volitional control over specific laryngeal muscles, reduce tension around the vocal cords and (sometimes) improve vocal quality. EMG biofeedback has also been found effective for treating rare cases of ventricular fold dysphonia and paradoxical vocal cord motion. Further research is needed with clearer specification of electrode placement. However, EMG biofeedback represents a promising application of behavioral technology in the treatment of various functional dysphonias and voice disorders.

Key Words: EMG, biofeedback, dysphonia, voice disorders, vocal tension, vocal quality

Defining Biofeedback

In biofeedback, internal autonomic events such as heart rate, blood pressure, or muscle tension are electronically amplified, providing an individual with body (i.e., bio) information (i.e., feedback) that is commonly unavailable. By using electronic instruments to accurately measure, process, and "feed back" information about the body, an individual is able to learn to develop control over these internal physiological events (Shapiro & Surwit, 1979). That is, internal responses thought to be involuntary have been found to be affected by consequences (i.e., operant learning) and subject to voluntary control as well. Indeed, empirical research has repeatedly demonstrated that through operant learning, humans can gain volitional control over numerous different internal physiological functions and the principle means of developing this control has been with consequences delivered via biofeedback (Schwartz & Olsen, 1995).

The importance of biofeedback in learning to control internal physiology should not be surprising. Skinner predicted as much when he suggested that, "there is no reason why covert behavior could not be amplified so that the individual himself could make use of the additional information..." (pg 282) (Skinner, 1953). Indeed, much of the research on biofeedback has been made possible precisely because of significant advancements in instrumentation for measuring covert physiological behavior (Peek, 1995). Biomedical engineers have developed noninvasive and sophisticated technology for using surface recordings to measure what goes on inside the body. Thus, we can now accurately and reliably monitor, amplify, and transform physiological behavior into audio and or visual signals that are easily understandable. An individual can sit casually in front of a computer, have sensors taped to their skin, and watch a computer monitor to receive information about what is going on within the skin. The biofeedback allows individuals to experience immediate, frequent and potent consequences for even small changes in covert behavior; all features known to enhance the reinforcing effects of consequences during operant learning trials (Miltenberger, 2001).

Defining Surface EMG (sEMG) Biofeedback

One type of biofeedback involves electromyography. An electromyogram is a record of electrical activity from a muscle or group of muscles. The electrical activity is typically reported in microvolts ([micro]V). When that record is obtained from electrodes applied to the skin and the information is used to control muscle activity, it is called surface electromyographic (sEMG) biofeedback. The specificity of the biofeedback from surface muscles depends in part, upon the specificity of the signal, which is influenced by the arrangement of the electrodes. Electrodes placed close together and parallel to the muscle fibers will provide more specificity with respect to the targeted muscles, while electrodes placed farther apart and/or perpendicular to the muscle fibers will provide a more global measure of tension in the targeted area (Fogel, 1995; Sherman, 2003).

Biofeedback effects can also depend upon how the feedback is delivered. For example, when using continuous feedback, the patient is provided with an ongoing signal that reflects the entire range of muscle activity. As with any type of operant learning, continuous feedback is thought to be particularly helpful when shaping a new skill. In contrast to continuous feedback, threshold feedback restricts feedback so that it occurs only in response to the presence or absence of a desired response. For example, a tone or light may come on (or turn off) only when a specified threshold of muscle tension is achieved. This intermittent feedback may be particularly helpful in refining and maintaining general responses (Peek, 1995).

sEMG biofeedback is considered a noninvasive procedure and it provides immediate, objective information about underlying muscle activity. Research on the modification of apparently "involuntary" isolated muscle contractions using sEMG represented a major early application of operant conditioning. For example, adult subjects initially were found to be able to voluntarily control vasomotor activity, but only when they were able to observe a polygraph record of their own continuous physiological changes (Razran, 1961). Others found that giving subjects feedback permitted operant conditioning of electrodermal (i.e., galvanic skin response) activity (e.g., Fowler & Kimmel, 1962).

Some 60 years later, sEMG continues to be an important avenue for the transfer of behavioral technology into applied settings using operant conditioning. For example, sEMG biofeedback has recently been used to treat temporomandibular disorders (e.g., Crider, Glaros, Gevirtz, 2005), fecal incontinence (e.g., Dannecker, Wolf, Raab, Hepp, Anthuber, et al., 2005), muscle tension headaches (e.g., Grazzi, Andrasik, D'Amico, Leone, Moschiano, Bussone, 2001) and stroke-related dysphagia (e.g., Crary, Carnaby, Groher, Helseth, 2005).

Defining Dysphonias

The use of sEMG biofeedback in the treatment of dysphonias represents another particularly promising area of application. In muscular tension dysphonia, vocal production is impaired, characterized by strangled, strained, or severe hoarseness in voice quality, vocal fatigue, and even throat pain while speaking (Redenbaugh & Reich, 1989). The impairment in vocal production is thought to result primarily from excessive muscle tension in the paralaryngeal areas that can result in structural abnormalities such as mucosal changes and fleshy vocal nodules (e.g., Morrison, Nichol, and Rammage, 1986). Note, however, that there are myriad terms that appear to be synonymous with muscle tension dysphonia, including functional dysphonia, functional hypertensive dysphonia, and hyperfunctional dysphonia (Altman, et al., 2005). These functional dysphonias also involve impaired vocal production characterized by muscle tension and vocal hoarseness, fatigue, and pain, but are often delineated by the absence of structural lesions (e.g., House and Andrews, 1988). Unfortunately, there is not wide agreement on classification schemes or underlying etiologies (Altman et al, 2005). Treatments for both muscle tension and functional dysphonias have included patient education, vocal rehabilitation, and even psychotherapy, but sEMG biofeedback is a logical consideration because of the suspected muscle tension involved.

sEMG Biofeedback for Dysphonias: Uncontrolled Research

Numerous studies of sEMG biofeedback have involved pre-post treatment evaluations of tension and voice quality in the targeted subjects, but have failed to establish clear experimental control. Experimental control is said to be demonstrated when one can reasonably conclude that changes in the dependent variable (e.g., tension) are a function of the changes in the independent variable (sEMG). Experimental control is generally arranged by the random assignment of some subjects to a control group; that is, a comparison group that receives either no treatment or receives an established alternative treatment or a credible placebo. Researchers can also demonstrate experimental control by employing small N (single subject) research designs. These designs generally require some replication of treatment effects within and/or across no-treatment (baseline) and treatment conditions. For example, treatment may be introduced sequentially across two or more responses or across two or more participants after varying amounts of time in baseline. Or, treatment may be introduced and then withdrawn repeatedly (e.g., see Barlow & Hersen, 1984 for a more complete discussion of these types of experimental designs). Arranging for a good demonstration of experimental control with either group or single subject designs helps increase the confidence that the outcomes were produced by the treatment and not by some other unmeasured or unaccounted for variable.

In one uncontrolled investigation, Prosek et al (1978) treated six patients with excessive laryngeal tension using 14, 30 minute sEMG biofeedback sessions. The electrodes were placed over the cricothyroid region, about 1 cm from midline, with a ground electrode on the earlobe. During the 14 biofeedback sessions, participants received both continuous and threshold auditory feedback (tone) as they read passages or engaged in conversation. The pitch of the tone corresponded to the level of laryngeal tension but only was available at threshold levels of tension. They were instructed to lower their tension to a preset threshold. When they had achieve 80% below threshold, the threshold was lowered another 5[micro]V. At the end of treatment, pre and post treatment voice quality was rated by a panel of speech pathologists.

Three of the six subjects reduced their laryngeal EMG levels during speech with a corresponding improvement in voice quality. However, two subjects experienced no or very small changes in sEMG levels and no changes in voice quality. One subject did experience marked changes in sEMG levels, but also did not experience changes in voice quality. The authors noted that these patients had structural damage as well as excessive muscle tension and concluded that sEMG may be more useful for patients with functional dysphonias.

Stemple, Weiler, Whitehead, and Komray (1980), also conducted an uncontrolled evaluation of sEMG with seven subjects with functional dysphonias. They used an unusually diverse electrode placement pattern; one was placed on the left thyroid lamina, one on the ear lobe and a reference or ground electrode under the chin. Subjects underwent 8 training sessions in which they were instructed to lower both visual and auditory continuous feedback during silent and speaking conditions. Four independent judges rated voice quality after treatment. Subjects were able to significantly reduce tension levels during both silent and speaking conditions with corresponding improvements in voice quality.

Several additional studies have investigated sEMG biofeedback as one component of a treatment package targeting dysphonias. Henschen & Burton (1978) used both visual and auditory sEMG biofeedback to treat 2 individuals with dysphonia, but they also included progressive muscle relaxation as a part of the intervention. They found that both subjects were able to reduce frontalis and throat muscle tension, however, neither subject reported subjective improvement in their own voice quality. Sime and Healy (1993) reported decreases in muscle tension as well as improvements in voice quality using sEMG biofeedback, but they combined it with voice therapy, cognitive behavioral therapy, and computer aided fluency training. Finally, Earles and colleagues combined sEMG biofeedback with several other types of biofeedback to target not just laryngeal muscle tension but also generalized relaxation (Earles, Kerr, & Kellar (2003).

In sum, these investigations suggest that, at least for some individuals, sEMG biofeedback may offer benefits with regard to reducing muscle tension and improving voice quality. Unfortunately, in each of these preceding investigations, the absence of a no-treatment or alternative treatment control condition raises concerns about uncontrolled or unmeasured sources of influence. In addition, for those studies involving sEMG as a part of a treatment package, the inclusion of multiple treatment modalities (e.g., voice therapy, fluency training, progressive muscle relaxation, etc) make it impossible to evaluate the independent effects of the sEMG biofeedback. However, several other investigators have conducted controlled evaluations of the effects of sEMG alone in treating dysphonias.

sEMG Biofeedback for Dysphonias: Controlled Research

Andrews, Warner, & Stewart (1986), conducted a small group comparison in which 5 patients with dysphonia participated in sEMG biofeedback. Five other individuals with dysphonia participated in an alternative treatment involving progressive muscle relaxation. For those who received sEMG biofeedback, electrodes were placed over the cricothyroid muscle, although the arrangement was not specified. Using continuous feedback, subjects attempt to lower tension levels to below 30[micro]V. Duration of treatment ranged anywhere from 4-36 weeks. The investigators found that sEMG biofeedback significantly lowered laryngeal tension (as did the relaxation training) with corresponding improvements in self-rated voice quality.

Allen, Bernstein, & Chait (1991) treated a 9 year old boy with dysphonia and vocal nodules. The electrodes were placed ipsilaterally and vertically, in parallel alignment along the thyrohyoid membrane. After stable baseline measures were collected during quiet and speaking conditions, the subject received continuous visual biofeedback during biweekly, 30 minute sessions. A criterion was established based on his individual baseline data. During resting and speaking conditions, the criterion was lowered .5[micro]V and 5[micro]V respectively, each time the established criterion was met during at least 80% of the trials for three consecutive sessions. Voice quality was evaluated by both speech pathologists and the subject's parents. Results showed marked reductions in muscle tension that were maintained at 3 and 6 month follow-up. Commensurate with decreases in laryngeal muscle tension were significant improvements in independent ratings of voice quality. Finally, endoscopic evaluations post treatment showed significant reductions in the vocal nodules during treatment and elimination at 6 month follow up.

These two studies provide an increased level of confidence in the effects of sEMG biofeedback because of efforts to establish experimental control. Andrews et al (1986) included a two-group comparison, demonstrating that sEMG biofeedback can produce outcomes at least as beneficial as an established relaxation treatment. The experimental design by Allen et al, (1991) demonstrated even more rigorous experimental control by showing stepwise reductions in the average level of muscle tension that corresponded directly with the changing criterion levels. Experimental control was also demonstrated in that the biofeedback was introduced first during the silent condition and then with the speaking condition. This sequential introduction across two responses showed experimental control when tensions levels began to drop after, and only after sEMG biofeedback was begun.

sEMG Biofeedback Treatment of Rare Voice Disorders: Controlled Evaluations

In addition to the preceding evaluations of sEMG biofeedback as a treatment for dysphonia, sEMG has also been used to treat less common disorders that involve excessive levels of tension in and around the paralaryngeal area. For example, Allen and colleagues used a small n research design to demonstrate experimental control of laryngeal muscle tension using sEMG to treat ventricular fold dysphonia (Watson, Allen, and Allen (1993). Ventricular fold dysphonia is a rare type of voice disorder in which muscular tension in the throat forces ventricular folds to adduct over the true vocal cords during phonation while the true vocal folds remain open. These false vocal folds are then used to produce speech, resulting in an animal-like, hoarse, or strangulated voice.

Watson et al. used electrodes placed ipsilaterally and vertically, in parallel alignment along the thyrohyoid membrane (Watson, et al., 1993). Stable baseline measures were collected during three response conditions; nonvocalizing, counting and conversation. Then, in a multiple baseline design, sEMG was introduced sequentially across the three responses conditions during biweekly, 30 minute sessions. Initial criteria were set at 5 [micro]V below the mean of the last three baseline measurements. Subsequent criteria were set at 5 [micro]V below the previously established criterion and were changed each time the established criterion was met during at least 80% of the trials for three consecutive sessions. Voice quality was evaluated by four speech pathologists. The results showed stepwise reductions in the average level of muscle tension across each of the targeted responses with the introduction of sEMG biofeedback training. In addition, the changes corresponded directly with the changing criterion levels. Finally, voice quality was rated as significantly improved while endoscopic evaluations showed no characteristics of ventricular phonation present.

More recently, Warnes and Allen, (2005) used sEMG biofeedback to treat a 16 year old girl who had a two year history of paradoxical vocal fold motion. In contrast to ventricular fold phonation and the other dysphonias, with paradoxical vocal fold motion (PVCM), the excessive laryngeal muscle tension causes the vocal folds to involuntarily adduct during inhalation, restricting the airway opening. The etiology of this condition is not clear, however, causes such as stress, upper airway sensitivity, gastric reflux disease, and neurological movement disorders have been suggested (e.g., Mathers-Schmidt, 2001). Patients with this type of covert muscle activity report chest pain, symptoms of labored breathing, harsh respiratory sounds, and feelings of being choked. Precipitants often include exertion, airborne pollutants, very cold air, and stress. Symptoms are often confused with and mistreated as asthma, at times resulting in emergency room visits and hospitalizations. Treatment of PVCM has typically focused on patient education, supportive counseling, progressive muscle relaxation training or controlled breathing exercises in an indirect effort to relax the throat muscles (Mathers-Schmidt, 2001).

For the patient in this investigation, over a year of controlled breathing exercises and progressive muscle relaxation had failed to reduce complaints of chest pain, labored breathing, and feelings of being choked. The patient often missed school. During treatment, sEMG electrodes were placed ipsilaterally along the long axis of the thyrohyoid membrane, using the thyroid cartilage as an anatomical marker. During baseline, average levels of muscle tension were recorded. During treatment, the patient could view a continuous visual representation of her muscle tension in the form of a vertically moving green bar. A preset "success" criterion was represented by a stable horizontal bar and was set at 2 microvolts below her baseline levels. She was instructed to try to relax and lower her observed muscle tension levels (and the green bar) below the stable horizontal criterion bar at which time the moving vertical bar would turn from green to red. A new criterion was set when the patient achieved three consecutive sessions at or below the current criterion. Two, 10 min EMG biofeedback sessions were conducted once per week over the course of 10 weeks.

EMG biofeedback was found to be an effective means of gaining control over muscle tension near the vocal cords in this adolescent female. During sEMG biofeedback, stepwise reductions in laryngeal muscle activity were observed with each criterion change. In addition, wide variability in muscle tension was stabilized by the completion of treatment. Baseline tension levels were reduced over 60% with corresponding reductions in episodes of respiratory distress and chest pain. Most important for this participant was the improvement in adaptive functioning as evidenced by an elimination of disorder-related school absences.

Summary and Future Directions

In spite of these numerous studies citing general support for sEMG biofeedback in treating dysphonias and related voice disorders, one is struck by the relatively small number of controlled investigations. Only the studies by Allen and colleagues demonstrated good experimental control yet each of these studies used a single subject. Additional controlled investigations are required to clearly establish the generalizability of the effects with more representative samples. Controlled outcome studies are also important to evaluate the extent to which observed changes are truly related to the biofeedback or to some nonspecific effect from the training. Including no-treatment control groups and also credible placebo control groups is important for establishing the independent effects of sEMG biofeedback.

Future research must also attend much more carefully to the specific procedures used in conducting biofeedback training. For example, the information that is output from the electronic equipment during biofeedback is only as good as the information input and that input is strongly influenced by the placement of the electrodes. The placement of the electrodes should isolate the muscles signal as much as possible with closely aligned electrodes that are parallel rather than perpendicular to the muscle fibers (Fogel, 1995; Sherman, 2003). Previous studies, however, have not reliably provided information about the placement, the spacing, and alignment of the electrodes (e.g., Prosek et al., 1978; Andrews, et al., 1986), even though these features are known to impact the specificity of the input. Placements that sum activity from diverse sites may provide information that is too general. In addition, electrodes spaced widely and not aligned along the same muscle fibers (e.g., Stemple et al, 1980), may provide very general information about overall tension levels near the targeted muscle groups but provide no specific information about the targeted muscle groups themselves. Biofeedback training might then produce reductions in general tension levels around the laryngeal muscles but have no specific impact on them. This may account for the failure of some investigators to find a relationship between sEMG and voice quality (e.g., Schliesser, 1987) leading others to conclude, perhaps erroneously, that sEMG is not appropriate for improving voice quality (e.g., Maryn, DeBolt, Cauwenberge, 2006).

Finally, some have suggested that biofeedback may not be a practical intervention (Maryn et al, 2006). Concerns about equipment costs are probably justified, especially with sEMG biofeedback, where simple, portable sEMG units begin around $850 and computerized systems begin around $2000. However, concerns that feedback may not be reinforcing enough for children seem unfounded. Indeed, biofeedback may hold particular appeal for children precisely because of the technology and computer based systems involved (Allen, 2004). In fact, some researchers have suggested that children are more enthusiastic, less skeptical, and quicker learners than adults (e.g., Culbert, Kajander, Reany, 1996). In addition, biofeedback has been repeatedly demonstrated to be an effective and efficient treatment for children with health-related problems (e.g., Hermann, Kim, Blanchard, 1995).

Overall, these studies suggest that sEMG biofeedback can be an effective alternative treatment for a variety of functional dysphonias and vocal cords disorders, at least for some individuals. The combination of sophisticated electronic technology and operant learning can be a powerful teaching tool and therapeutic agent. By making subtle changes in muscle tension near the vocal cords more salient and by arranging for immediate and frequent reinforcement of changes in the desired direction, most of the participants in these investigations were each able to achieve selective control of these covert behaviors and improve voice quality. Of course, this is not to suggest that sEMG biofeedback should replace alternative treatments that have been found successful, such as voice therapy, vocal hygiene, and manual tension reduction (Altman et al., 2005). Although sEMG biofeedback appears to hold promise as an applied behavioral technology that can make important contributions to the phonatory health and performance of individuals, further research is required.

Acknowledgement

This project was supported in part by (1) Project #8188 from the Maternal and Child Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services and (2) Grant 90DD0533 from the Administration on Developmental Disabilities (ADD), Administration for Children and Families, Department of Health and Human Services.

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Author Contact Information

Keith D. Allen, Ph.D.

Munroe-Meyer Institute for Genetics and Rehabilitation

University of Nebraska Medical Center

986705 Nebraska Medical Center

Omaha, NE 68198-6705

(402) 559-4006

E-mail: kdallen@unmc.edu
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Title Annotation:Electromyographic biofeedback treatment
Author:Allen, Keith D.
Publication:The Journal of Speech-Language Pathology and Applied Behavior Analysis
Article Type:Report
Geographic Code:1USA
Date:Jun 22, 2007
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