ERIC EJ725243: Biofeedback Treatment of Paradoxical Vocal Fold Motion and Respiratory Distress in an Adolescent Girl

0.05 MB·English

by  ERIC

JOURNALOFAPPLIEDBEHAVIORANALYSIS 2005, 38, 529–532 NUMBER4 (WINTER2005)
BIOFEEDBACK TREATMENT OF PARADOXICAL VOCAL
FOLD MOTION AND RESPIRATORY DISTRESS IN
AN ADOLESCENT GIRL
EMILY WARNES ANDKEITH D. ALLEN
MUNROE-MEYERINSTITUTEFORGENETICSANDREHABILITATION
UNIVERSITYOFNEBRASKAMEDICALCENTER
In this investigation, we evaluated the effectiveness of surface electromyography (EMG)
biofeedback to treat paradoxical vocal fold motion in a 16-year-old girl. EMG biofeedback
training occurred once per week over the course of 10weeks. In a changing criterion design,
muscle tension showed systematic changes that corresponded with changes in the criterion.
Overall,baselinemuscletensionlevelswerereducedover60%,withcorrespondingreductionsin
episodesofrespiratorydistressandchestpain.Subjectivereportsbythepatientandthepatient’s
mother indicated improvements inschoolattendance andoverall adaptivefunctioning.
DESCRIPTORS: biofeedback, behavioral pediatrics, health-related behavior, children,
behaviormodification
_______________________________________________________________________________
Biofeedback involves the application of control of involuntary muscle activity during
operantconditioningtogaincontrolofvisceral, speech (Allen, Bernstein, & Chait, 1991;
somatomotor, or central nervous system activ- Watson, Allen, & Allen, 1993).
ities. Using biofeedback to modify apparently In contrast to the dysphonias, paradoxical
involuntary isolated muscle contractions repre- vocal fold motion (PVFM) involves excessive
sented a major early application of operant muscle tension that causes the vocal folds to
conditioning to covert activities (Shapiro & involuntarily adduct during inhalation rather
Surwit, 1979), and it continues to be an than vocalization, restricting the airway open-
important avenue for the transfer of research- ing. Patients with this type of covert muscle
based behavioral technology into applied set- activity report chest pain, symptoms of labored
tings. For example, biofeedback has proven to breathing,harshrespiratorysounds,andfeelings
be effective in the treatment of some vocal cord of being choked. Symptoms are often confused
disorders. In dysphonias, excessive muscular with and mistreated as asthma, at times
contractionwithinthevocaltractleadstosevere resulting in emergency room visits and hospi-
hoarseness, vocal fatigue, and even throat pain talizations. Treatment of PVFM has typically
while speaking (Redenbaugh & Reich, 1989). focused on progressive muscle relaxation train-
Dysphonias can be difficult to treat but have ing or controlled breathing exercises in an
responded to the use of biofeedback to teach indirect effort to relax the throat muscles
(Mathers-Schmidt, 2001). Biofeedback, on the
This research was supported in part by Project 8188 other hand, offers more direct impact and the
from the Maternal and Child Bureau (Title V, Social
possibility of differential control of excessive
Security Act), Health Resources and Services Administra-
tion, Department of Health and Human Services and involuntary muscle activity. However, there are
Grant 90DD0533 from the Administration on Develop- no reported applications of biofeedback to
mental Disabilities, Administration for Children and
PVFM. The purpose of this investigation was
Families,Department ofHealthandHuman Services.
Correspondence concerning this article may be sent to to evaluate the effectiveness of electromyo-
Keith D. Allen, Munroe-Meyer Institute, 985450 Ne- graphic (EMG) biofeedback as a treatment of
braskaMedicalCenter,Omaha,Nebraska68198(e-mail:
PVFM and to evaluate the impact of treatment
[email protected]).
doi:10.1901/jaba.2005.26-05 on pain and adaptive functioning.
529
530 EMILY WARNES and KEITH D. ALLEN
METHOD treatmentwasconducteduntilthenewcriterion
level was met and stability at that level was
Participant
achieved. Treatment continued until typical
The participant was a 16-year-old Caucasian
levels of muscle tension for that location near
girl with a 2-year history of PVFM. Diagnosis
the vocal cords were achieved.
was confirmed via visual inspection through
a fiber-optic laryngoscopic exam by an otolar-
Procedure
yngologist (Mathers-Schmidt, 2001). The par-
The participant attended a university-based
ticipant reported daily chest pain, labored
clinic for biofeedback training on average once
breathing, and feelings of being choked. She
per week over the course of 10 weeks. During
frequently missed school. Previous attempts at
theinitialpretreatmentbaseline,followinga10-
treatmentoverthepast12 monthshadinvolved
min habituation period, EMG measures of
controlled breathing exercises recommended by
muscle tension were recorded when no visual
a speech therapist.
feedback was presented. Two sessions of pre-
treatment baseline data were collected before
Dependent Measures
biofeedback treatment began.
Electromyographic measures. EMG data were
During treatment sessions, each visit began
collectedviaacomputerizedbiofeedbacksystem
witha5-minrestingbaseline(i.e.,nofeedback),
and visual monitor. Data were recorded in
followed by two 10-min biofeedback sessions
microvolts (mV) and collected continuously
with a 5-min break between each session.
throughout each of the biofeedback sessions.
During biofeedback sessions, the participant
EMGsurfaceelectrodeswereplacedipsilaterally couldview avisualrepresentation ofhermuscle
and vertically in close, parallel alignment along tension in the form of a moving vertical green
the long axis of the thyrohyoid membrane, bar. The preset criterion was represented by
using the thyroid cartilage (i.e., the Adams astabledarkhorizontalbar.Shewasencouraged
apple) as an additional anatomical marker. to tryto relax andto lowerherobservedmuscle
Pain measures. The participant recorded tension below the preset criterion; this would
PVFM pain four times each day using a visual change the vertical moving bar from green to
analogue scale ranging from 0 to 10, with 0 5 red. No specific instructions were provided
no pain, 5 5 moderate pain, and 10 5 severe about how to accomplish this other than to
pain. watch the feedback. She was instructed to ‘‘try
Adaptive functioning. The participant re- to relax the muscle tension near your vocal
ported anecdotal evaluations of her adaptive cords to below the criterion line on the
functioning before and after treatment, and her computer screen, using the feedback to guide
mother completed a questionnaire rating pain you.’’ Average microvolts per session were
interference (0 5 no interference and 6 5 calculated. The initial criterion level was set at
extreme interference) with adaptive functioning 10 mV (2 mV lower than the average baseline
inday-to-dayactivities(Allen&Shriver,1998). levels). Subsequent criteria were determined
according to the following set of rules: (a) A
Experimental Design new criterion was set when the participant
A changing criterion design was used. After achieved three consecutive sessions at or below
determining baseline levels of muscle tension, the current criterion. (b) Criterion goals were
treatmentinvolvedtheuseofEMGbiofeedback set2 mVlowerthanthepreviouscriterion.(c)If
until a lower muscle-tension criterion was met twoormoreconsecutivesessionswereabovethe
and stability at that level was achieved. At that current criterion level, the criterion was raised
point, a more stringent criterion was set, and 1 mV. During the 5-min break, the participant
BIOFEEDBACK 531
Figure 1. Average microvolts per session across baseline and treatment conditions. Horizontal lines and
corresponding numbersinparentheses indicate changing criterion levels.
viewed a graph depicting her performance over tension level of 5 mV (range, 3 to 5 mV). Thus,
thepast10 mininrelationtothecriteriongoal. termination of biofeedback training occurred
when the participant achieved a typical level of
muscle tension.
RESULTS AND DISCUSSION
There also were corresponding reductions in
EMG biofeedback was found to be an episodes of respiratory distress and chest pain.
effective means of gaining control over muscle Dailypainratingsmaintainedbytheparticipant
tension near the vocal cords. During EMG during baseline showed that daily pain episodes
biofeedback, stepwise reductions in laryngeal with moderate to severe pain ratings (i.e.,
muscle activity were observed with each crite- ratings of 4 or above) occurred 3 to 4 days
rion change (see Figure 1). In addition, wide per week. By the sixth biofeedback session, the
variability in muscle tension was stabilized by participant reported zero pain episodes per
the completion of treatment. Overall, baseline week, and no pain or respiratory distress
tension levels were reduced over 60%. Bio- episodes were recorded thereafter. Most impor-
feedback treatment concluded when the partic- tantforthisparticipantwastheimprovementin
ipant demonstrated stability below the 5-mV adaptive functioning, as evidenced by an
criterion level. To help determine an appropri- elimination of disorder-related school absences.
atecriterionfortermination,normativebaseline Prior to biofeedback training, the participant
datawere collected from fivefemales ranging in reported missing 25% of all school days due to
age from 13 to 30 years with no history of distress and pain associated with PVFM.
asthma or vocal cord dysfunction. Normative Following the sixth session, no school absences
data revealed an average laryngeal muscle due to PVFM symptoms were reported. At the
532 EMILY WARNES and KEITH D. ALLEN
conclusion of treatment, the participant re- covert behavior. By making subtle changes in
ported that she was pleased with the results of muscletensionnearthevocalcordsmoresalient
thebiofeedbacktherapyand‘‘happytonotmiss and by arranging for immediate and frequent
any more school or extracurricular activities.’’ reinforcement of changes in the desired di-
Finally,the motherreported marked reductions rection, this participant was able to achieve
in interference of daily functioning by PVFM clinically significant selective control of these
symptoms from baseline (mean rating 5 5) to covert responses.
treatment (mean rating 5 0).
Although the experimental design permits
REFERENCES
reasonable conclusions about the effectiveness
of EMG biofeedback in changing muscle Allen, K. D., Bernstein, B., & Chait, D. (1991). EMG
biofeedback treatment of pediatric hyperfunctional
tension in this individual, there are several
dysphonia. Journal of Behavior Therapy and Experi-
factors that limit other conclusions that can be mentalPsychiatry,22,97–101.
drawn from these data. For example, the Allen, K. D., & Shriver, M. D. (1998). Role of parent-
mediated pain behavior management strategies in
generalizability of these results to other indi-
biofeedback treatment of childhood migraine head-
viduals with PVFM is unknown. In addition,
aches.BehaviorTherapy,29,477–490.
the changes in adaptive functioning may reflect Mathers-Schmidt, B. A. (2001). Paradoxical vocal fold
nonspecific effects derived from the intensive motion: A tutorial on a complex disorder and the
speech-language pathologist’s role. American Journal
nature of services rather than anything unique
ofSpeech-Language Pathology,10,111–125.
to the biofeedback. Finally, the sample of
Redenbaugh,M.A.,&Reich,A.R.(1989).SurfaceEMG
women used for normative comparison was and related measures in normal and vocally hyper-
quite small, and their observed muscle-tension functional speakers. Journal of Speech and Hearing
Disorders, 54, 68–73.
levels may not have been representative of
Shapiro, D., & Surwit, R. (1979). Biofeedback. In O. F.
typical tension levels in muscles near the vocal Pomerleau&J.P.Brady(Eds.),Behavioralmedicine:
cords. Theoryandpractice(pp.45–73).Baltimore:Williams
In spite of these limitations, this study &Wilkins.
Watson, T. S., Allen, S. J., & Allen, K. D. (1993).
suggests that EMG biofeedback can be an
Ventricular fold dysphonia: Application of biofeed-
effective alternative to conventional relaxation back technology to a rare voice disorder. Behavior
therapies in the treatment of PVFM. It also Therapy,24,439–446.
demonstrates that the combination of sophisti-
Received March 4,2005
cated electronic technology and operant tech-
Final acceptance June30,2005
nology is powerful in teaching control over Action Editor,Douglas Woods