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Stroke and voice recovery from a singer-pedagogue's perspective.

SINGERS, VOICE PEDAGOGUES, AND CHORAL CONDUCTORS of all ages have experienced vocal abuse and damage due to the constant teaching and use of their voices during the day. Increasingly prevalent, however, are singers who have suffered some sort of brain injury, damage, or stroke. Some injuries and their rehabilitation have been investigated scientifically and reported in periodicals such as the Journal of Voice, This article, however, is written not from the point of view of a medical professional or speech-language pathologist (SLP), but as one who has had a stroke, and has had to design vocal rehabilitation largely for himself, outside the scope of physical, occupational, and speech therapy, and without benefit of an otolaryngologist.

It has been over twelve years since I had a stroke. Fortunately, it was relatively mild, and nearly all my vocal facility has been regained. Several years ago I wrote an article for the Choral Journal on "One-Handed Choral Conducting," but that seemed easy by comparison. (1) Recovery has not been easy nor without frustration. Further, the process has had manifold effects on my work as a singer and pedagogue.

BRIEF DESCRIPTION OF STROKE

Cerebrovascular accident or brain attack--these are often used to describe a stroke. Briefly stated, blood dots in the brain, or a vessel that weakens or breaks, causes blood loss to that area which can destroy vital nerves controlling other parts of the body. Mine, an ischemic attack, which is blood starvation from a clot blockage, affected a two-centimeter area in the left brain, just above the basal ganglia, and resulted in numbness on the right side. Over twelve years much function has been regained, save my right hand's fine motor skills. At the outset, there was also some vocal fold paresis (slight weakening of one side of the vocal folds). As a singer and voice teacher, this was most frustrating and required the most attention and creativity in developing my own methods of rehabilitation, both in speaking (with the assistance of a SLP), (2) and singing (developed mostly on my own, from traditional vocalises with the aid of a sensitive singing teacher). (3)

There are different gradations and types of cerebrovascular and other brain diseases. My problem might not be the same as that of another individual, nor of someone with a stroke or injury affecting another part of the brain, because each case is unique. Traditional therapy deals with larger motor skills, and a few fine motor and speech skills, but does little with the singing voice, especially considering financial coverage limitations of health insurance carriers in the United States, which often pay only for what is needed to return a person to basic functioning skills. Singing therapy is available mainly to those who live in or near large population centers with a base of well trained specialists in voice therapy. My rehabilitation as a singer had to be self-designed because of my health insurance at the time--an individual policy from a major insurer, which would pay only for returning me to society as a functional speaker. It would not cover the cost of rehabilitating my singing voice, even though this was my wage-earning profession.

PERSONAL HISTORY AND RECOVERY

My stroke happened during the night of June 27, 1998. Waking in the morning, I gradually became aware that I had difficulty signing my name throughout the day, and felt exhausted. I checked myself into the emergency room, where I was hospitalized for five days, having CAT scans, MRIs, and heart blockage tests. The MRI showed a two-centimeter ischemic attack near the basal ganglia on the left side of the brain, near the center. (4)

Following my stay at a regular hospital, I was transferred to a rehabilitation hospital, where I spent another seven intensive days, and continued outpatient therapy for another three months, being discharged in late September. In the regular hospital, I became aware of numbness in my right hand, arm, and leg, and some sluggishness of speech, droopiness of the right side of my mouth (later, when more cognizant, some slight vocal fold paresis), and slightly later, some difficulty in singing.

For the first week (inpatient) in the rehabilitation hospital, I concentrated on basic function--standing, walking, and just moving my right arm and hand. Primarily, I had guidance and assistance from the therapists and nurses as I slowly worked for recovery. But more important questions for myself as a singer began to arise as I continued to recover. What was my vocal function? Would I be able to sing normally? If so, how long would rehabilitation take? And how does one cope with the rehabilitation of the voice through all this? Following is a result of my experience.

Therapy

In the rehabilitation hospital, the week of intensive inpatient therapy gave way to three months of outpatient therapy, followed by work on my own. Reestablishing brain connections or developing alternative neuropathic roots for those connections takes time and can be frustrating. Therapy included several areas.

Leg function and right-arm function. This included gross and fine motor skills. I proceeded from basic movement exercises to Thera-Band resistance bands of various strengths on my right arm and leg. This was followed by push-ups, free weights, and resistance weights. Fine motor skills were gradual and included grip strength, grasping, reaching, and eventually, keyboarding and writing.

Speech therapy. Fortunately, I had only extremely mild aphasia. About a week into my outpatient rehabilitation, I was assigned a speech therapist for three one-hour sessions per week, plus given exercises to do on my own (Figure 1). These exercises were designed to regain the independence of my speech muscles, to relieve a slight right vocal fold paresis, and to relieve the droopiness of one side of my mouth. Additionally, I developed exercises beyond these which were practiced two to three times per day. They included: tongue consonants followed by vowels, especially l, n, t, d, followed by [i], [e]; words and sentences, selected by a speech-language pathologist; then on to words and simple sentences of three to twelve syllables in length. (Examples of these can be found in Sataloff, Treatment of Vocal Disorders). (5) The philosophy of speech-language pathology is somewhat changed and is more holistic, relying more on verbalizations from patient experience. Eventually, I went through the entire Moriarty diction book over several months, further honing my skills on vowel and consonant combinations in a variety of languages. (6)
Figure 1. Initial Laryngeal Adduction Exercises
for Vocal Fold Paresis.

1. Bear down by pulling up on the chair you are seated in or
pressing palms down on table and hold for 10 seconds.

2. Produce rapid and sharp "ah" for 10 to 25 seconds.

3. Cough with much force and effort.

4. Falsetto: say "ah" or "ee" while gradually raising the raising
the pitch.

5. Vocalize a sustained "ah" for up to 25 seconds.

6. Push your palms together while saying sustained "eeeeeeeeee."

7. Vocalize while inhaling. Draw your breath in while saying
"eeee."

Each of these exercises can be repeated 5-10 times depending
upon your endurance. They should be completed 3 times per day.

New thought on speech therapy exercises for specific vowel and
consonant combinations, words, and phrases: There is spontaneous
speech recovery in all but the severest patients. Therapy seeks to
energize that speech, building upon it through conversation.

Madonna Rehabilitation Hospital


Lip and mouth range of motion (without speaking). Readers may have seen noted actor Kirk Douglas demonstrate these in his ads for stroke prevention several years ago. These involve pursing and extending the lips, without speaking. However, this has since fallen out of favor for more holistic speech therapy.

Falsetto and light head voice. The use of falsetto was also important to vocal rehabilitation, especially extending it downward and "blending in" for head voice. These were developed by me, based on previous exercises, not by a SLP.

Singing exercises. In addition, I developed rehabilitation exercises on my own, especially involving descending lip trills, starting high in the vocal range and descending into the middle, over a fifth and an octave, also practiced two to three times per day. Gradually, exercises opening the lip trill into a vowel [u], [o], [a], [e], [i], descending over a fifth, and then the entire vowel spectrum, were added. Throughout these exercises, I strove to maintain a steady stream of breath. After about a month, phrases and slow, short songs due to the slowness of speech were added (especially Alessandro Scarlatti), concentrating on vowel alone and vowel plus consonants. Mixed vowels (German and French) required still more work. It was difficult to roll r and pronounce combinations of two consonants due to a feeling of tongue "thickness" at first; this became better over several months, and speech became faster. I still use these exercises even though it has been years since my stroke; they are a part of my everyday vocalization, and I also use some of them with students for varied purposes and as a foundation in vocal study. A summary of these exercises is found in Figure 2.

Breath. At first, this was more difficult, coming in shorter bursts due to the slight vocal fold paresis and the greater effort. There was a tendency to overdo subglottic pressure at first in order to get sounds out, especially in the first few weeks. Gradually, strengthening of the vocal mechanism allowed for conscious subglottic pressure to subside, although there was no perceptible dysfunction in the breathing musculature on the right side.

[FIGURE 2 OMITTED]

Recital. Approximately nine months after my stroke, I gave a public recital consisting of forteen songs, in Italian, French, German, and English. Nine of the songs were new; five had been previously performed. While it was important to learn new material, the stability of some familiar repertoire, to which one could attach muscle memory, was also crucial (Figure 3).

Diuretic. Because I was now on a diuretic and additional medication to control blood pressure, and blood thinners, first aspirin and then Plavix, hydration was now an issue. To avoid "dry mouth," extra water was necessary, as well as care in approaching louder pitches in order to avoid vocal fold damage.

Almost ten months after my stroke, I performed the tenor solos in Orff's Carmina Burana with orchestra. This was helpful in my recovery, especially for use of the upper register, given the extreme range and tessitura.
Figure 3. Faculty Recital, March 16, 1999, Hastings
College, Hastings, Nebraska.

Toglietimi la vita ancor           Alessandro Scarlatti
Cara e dolce                       (1660-1725)
Sento nel core

Ici-bas                            Gabriel Faure
Reve d'amour                       (1845-1924)
Adieu
Le ramier

Sapphische Ode                     Johannes Brahms
Wie bist du, meine K6nigin         (1833-1897)
Feldeinsamkeit

Orpheus with His Lute              Eric Coates
It Was a Lover and His Lass        (1886-1957)
Who Is Sylvia?

Not Even if I Try                  Kevin Oldham
                                   (1960-1993)


Application

My situation vs. others (more serious; easier). There are others who have had strokes who have varied situations. Some recover quickly, with little aftereffect. Others have debilitating paralysis and a paralyzed vocal fold or worse, and even with therapy, never recover full functionality. The biggest thing for me was that what was automatic now had to be governed by overly conscious thought. It was like being a child again, or a beginning voice student. My speech, singing, and movement were very calculated and devoid of spontaneity, though now that is gradually improving, even after ten years.

Mental attitude/self-concept. Adjustments in mental attitude were necessary, and it is an ongoing process. There are times when I become frustrated about what I can do versus what I once was able to do. Sometimes this involves borderline depression; I do my vocal rehabilitation exercises to help overcome this. Now my voice is almost returned to normal, especially in the perception of others. However, I no longer do "patter" songs and other fast diction pieces.

Keyboard. As a voice teacher, I had been a decent "utility" pianist, and a keyboard minor as both an undergraduate and masters student, accompanying my students. Now, I accompany left-handed, with some right hand on slow accompaniments. My students have learned an increased reliance on themselves, or on fellow student accompanists or piano faculty/staff accompanists. In fact, I let them stumble and work it out rather than "piano-feeding" them everything, or just play the chord structure, having them figure out where they are in relation to the chords. Further, I have utilized CD accompaniments that come with certain books (something I swore I would never do), and am now trying to master the nuances of a recently acquired Yamaha Disklavier so that I can further assist my students.

Choral teaching and conducting. The same principles apply to choral ensembles, where I teach using much less piano than previously (although I still have an accompanist), and use it only as a temporary aid with parts, as necessary, even in a community ensemble. Members of ensembles have risen to the occasion, realizing they have to rely on themselves more. As a conductor, I was primarily right-handed before the stroke. Now I am primarily left-handed, with much more reliance on one-handed conducting. Both beat pattern and dynamics can be controlled by one hand rather effectively, especially when one considers that size of pattern equals dynamics. When multiple cues are involved, I coach the parts as to which one I will cue, and which voice part I will rely upon to count the cut-off for themselves. I also use "stop-cueing" more, to cut down on excess motion. Body centeredness is something that I also attempt to model for my singers, most of the time successfully. Finally, facial expression should be the key to musicality for every conductor, and I use it frequently, adjusting my expression for joyous or somber passages, or anything in between.

Exercise. Regular exercise now includes walking and bicycling for at least an hour nearly every day, unless the weather is inclement. Then I use an old Nordic track ski machine. Hydration issues continue to be a problem, especially now in the desert air of southwest Texas; I strive to keep hydrated.

Summary

My perspective on the voice and the choral ensemble has changed as a result of having to deal with vocal disability and my own rehabilitation. Changes in voice pedagogy for myself and students as a result of the stroke include:

1) more emphasis on spinal alignment and body mapping in students (and in self);

2) a greater emphasis on breath flow and legato (lip trill, raspberry);

3) more focus on student-centered pedagogy and musicianship; and

4) literature--there is sometimes a conflict over what I can play/fake at the piano versus what is best for student. I continually try to remedy this.

Of course, there is no presumption that the recovery program described here is necessarily widely applicable to other stroke victims. The "bottom line" is: Don't let a brain injury or stroke get you down. I survived this; with time and perseverance, the chances are so can you.

NOTES

(1.) Donald Callen Freed, "One-Handed Choral Conducting: Disability or Blessing?" Choral Journal 47, no. 2 (August 2006): 57-58.

(2.) Medical Records of Donald Callen Freed, Bryan/LGH Medical Center, Lincoln, NE (June 27-July 1, 1998).

(3.) Donna Harler-Smith, voice coaching and personal consultation, University of Nebraska-Lincoln.

(4.) Medical records, Madonna Rehabilitation Hospital (July l-September 15, 1998).

(5.) Robert T. Sataloff, Treatment of Voice Disorders (San Diego: Plural Publishing, 2005), 385-387.

(6.) John Moriarty, Diction (Boston: ECS Publishing, 1975).

Donald Callen Freed, Associate Professor of Vocal Music at Sul Ross State University, Alpine, Texas, previously served as Instructor of Voice at Hastings College, Hastings, Nebraska, as Visiting Instructor of Voice at the University of Nebraska-Lincoln, and Instructor of Vocal Music at Peru (NE) State College. He holds the PhD in voice pedagogy/choral music education, and the MM in voice, from the University of Nebraska-Lincoln; and the BM in vocal music from Nebraska Wesleyan University, Lincoln. Additional studies were at the University of Iowa, Roosevelt University, and Oberlin College.

Freed's teachers have included Donna Harler-Smith and Thomas Houser. He was one of twelve participants in the first National Association of Teachers of Singing Intern Program in 1991, where he studied with the late Barbara Doscher. He also has sung in several master classes with the late Richard Miller.

Dr. Freed is a published composer and received ASCAP composition awards from 2001 through 2010. His articles have appeared in The Choral Journal, for which he is a reviewer of books and music, The NATS Journal, and the Journal of Singing. He has presented papers, compositions, and lecture recitals at The College Music Society Great Plains and South Central Chapters, the National Association of Teachers of Singing, the Fourth International Conference on the Physiology and Acoustics of Singing, the Athens Institute for Education and Research, and the Nebraska and Texas Music Educators Associations.

A stroke survivor, he is a member of VSA Arts and interested in voice therapy and rehabilitation.
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Author:Freed, Donald Callen
Publication:Journal of Singing
Date:May 1, 2011
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