Acupuncture For The Treatment Of Adductor Spasmodic Dysphonia
Steven Scheer, MD; Linda Lee, PhD
Vol. 14, #3
Background Spasmodic dysphonia (SD), a rare neurologic spasm of the vocal folds, results in a chronic voice disorder that can affect patients’ quality of life. Current treatment, including surgery and botulinum toxin injections, produces inconsistent results.
Objective To investigate the use of acupuncture in the treatment of SD.
Design, Setting, and Participants Prospective case series of 10 individuals (n=9 women; mean age, 45 years) with adductor SD in a metropolitan Ohio area during 2001.
Intervention Eight sessions (1 week apart) of acupuncture using the LU-LI distinct meridian; during sessions 2-8, electrical stimulation was applied. Auricular acupuncture to “larynx” points during sessions 4-8
Main Outcome Measures Self-report of participants’ perception of sound and ease of voice production, as well as changes in vocal quality observed by speech/language pathologists and subjects’ associates.
Results There was no value in the LU-LI treatment without electrical stimulation. Seven of the 10 participants reported vocal improve-
ment, and 2 others noted improvement during specific times of the investigation. Seven rated satisfaction as 3 or higher on a 5-point scale. Seven individuals reported that others noted vocal improvement.
Conclusions Most participants reported improvement in vocal quality and speech production following acupuncture treatment. Further research of acupuncture for SD is needed.
Spasmodic Dysphonia, Voice Disorder, Acupuncture, Overadduction, Overabduction
he neurologic condition known as spasmodic dysphonia (SD) or uncontrolled spasm of the vocal folds results in a chronic voice disorder.1,2 Believed to be related to the focal dystonias that include blepharospasm, torticollis, and writer’s cramp, SD is defined as an extreme overadduction or overabduction of the vocal folds that interferes with phonatory vibration.3-6 SD does not respond well to conventional voice therapy, behavior modification, or oral antispasmodic medication.5
While SD is rare (current estimates are 1 case in 20,000 persons), for many individuals, it is extremely disabling in life and work.5 The range of onset is from 3 to 85 years, with a mean around 38 years. It occurs more often in women (58%) than in men (42%).6 There are adductor, abductor, and mixed types of the condition, and some patients have symptoms of other focal dystonias as well.6 In the most common form, the adductor type, voice production is characterized by strain and effort, pitch or voice breaks, and there are occasional complete blocks in the ability to sustain the vibratory cycle.7-9 Because of the hyperadduction of the vocal folds and the amount of effort needed to phonate during spasms, many patients complain of physical fatigue, tension in the muscles surrounding the neck, and shortness of breath. Some persons with SD develop fear of speaking that may interfere with holding a job or even maintaining relationships. Use of the telephone is especially difficult for others. Initial thoughts on the possible psychiatric origin of SD have since been discounted.3,4 The presumed central nervous system site of the pathophysiologic disturbance is in the basal ganglia; exactly where is unclear, as is the case with other focal dystonias.10,11
Until recently, persons with this development were forced to resort to either surgical resection of the recurrent laryngeal nerve or the laryngeal muscles, or to the injection of botulinum toxin into one or, rarely, both vocal folds.2,12 Dedo and Izdebski2 established a surgical approach involving unilateral resection of the recurrent laryngeal nerve. While the initial success was reportedly high, subsequent reports suggested that the return of vocal cord dystonia and a worsened vocal quality were as high as 60% in the 3-year follow-up period.12
Another surgical approach, laryngoplasty, caused vocal cord relaxation but with a potential sacrificed loss of pitch and loudness.12 A newer procedure developed by Berke et al12 that prevents reinnervation of the vocal cord adductor muscles appears promising, but is still being investigated.
Use of botulinum toxin was approved by the US Food and Drug Administration (FDA) in 1989 for treatment of blepharospasm (eyelid spasm).7-9 The toxin blocks the release of acetylcholine at nerve terminals. If directed to localized areas of innervated muscle, botulinum toxin can be an effective local paralyzer of unneeded muscle action.
Shortly after its FDA approval for blepharospasm, botulinum toxin was used off-label for the treatment of SD.7 Following injection, the paretic muscle loses its spasm, but the vocal quality after treatment is quite variable: some patients have only a whisper for a number of weeks after injection while others have only a brief remission from the spasm and a return of the entirety of vocal problems within a few months.8,12,13
The procedure is expensive ($500-$750 per injection) and must be repeated every 2-12 months indefinitely.8,12,14 Each injection is followed by occasional difficulty in swallowing.8,12 Over time, botulinum toxin may lose its effectiveness, perhaps due to calcification of the injected muscle.14 Unofficial estimates of the frequency with which botulinum toxin injection is used for disabling SD are approximately 75% of patients with the condition.
A group of academic speech/language pathologists at the University of Cincinnati learned of a limited case study on the use of acupuncture for SD in 1997.15 The patient who underwent acupuncture therapy for SD improved on all measures of voice parameters even after a 6-month follow-up period. The exact nature of the acupuncture treatment was not identified in the report and an attempt to reach the investigative team was unsuccessful.
The first author participated as one of two physician acupuncturists in a pilot study of individuals with adductor SD in metropolitan Ohio. We intended to identify, using a few types of acupuncture treatments, whether a combination of methods could improve acoustic measures of voice and perception of vocal quality. We also hoped to determine which of a battery of measurement procedures best described the effects of treatment.
Ten individuals with adductor SD were investigated during 2001. The participants were drawn from the files of local speech/language pathologists or were recruited through an advertisement in the local SD newsletter. Participants ranged in age from 31 to 70 years (mean 45 years). Nine of the participants were women.
Five individuals had never received botulinum toxin injections, either because they were newly diagnosed or because they had rejected its use. Of the remaining 5 who had received botulinum toxin in the past, we excluded from consideration any persons who been treated within 12 months of the 1st acupuncture session. None of the 10 had undergone surgical treatment for SD. All eligible individuals gave informed consent to participate. The research proposal was reviewed and approved by the institutional review board of the University of Cincinnati.
All clinical testing of speech variables was performed independently by 3 licensed speech/language pathologists from the University of Cincinnati or Miami University of Ohio. Main outcomes included measures of voice analysis (Kay Elemetrics Motor Speech Profile, CSL Model 4300B, Lincoln Park, NJ), and a self-report of participants’ perception of sound and ease of voice production (Voice Handicap Index16). Additional perceptual voice analysis was performed after participants were tape-recorded while reading a standard passage. After the treatments were completed, participants were asked a series of open-ended questions regarding their experience with the protocol, changes in vocal quality noticed by themselves, coworkers, or family members, and future plans regarding acupuncture. Participating physicians did not collect any data so as to minimize observation biases.
The acupuncture protocol (Table 1) was devised by two treating physicians, with input from Dr Joseph Helms and reference to primary texts.17,18 Each participant received 8 treatment sessions, spaced about 1 week apart. For each treatment, participants were placed on a padded plinth in the supine position. Music was played for added relaxation. Session 1 began with a brief description of the procedure to allay anxiety about acupuncture.
In each of the 8 sessions, the protocol required use of the LU-LI meridian17 (Figure 1) plus a focusing point at ST 9, electrically stimulated for all but the 1st session: LU 1 and LI 15 (crossed for negative black clip), LI 18 and ST 9 (crossed for positive red clip). Needles at ST 9
(Figure 1) were directed inward toward the middle of the thyroid cartilage lamina. Stainless steel Seirin 40- and 6-mm needles were used for the LU-LI meridian approaches. During sessions 2-8, a 3-channel electrical stimulator (OMS Medical Supplies Inc, Braintree, Mass) was used at either 80 Hz or 15 Hz. The needles were left in place for approximately 30 minutes. For body tonification points electrically stimulated during the 8th session, 2.5 Hz frequency was chosen. During sessions 2 through 8, attempts were twice made to turn up the intensity of electrical stimulation during each session to enhance the effect.
Ear acupuncture, used initially in session 4, featured double needling of both the French and Chinese “larynx point,” located respectively on the medial surface of the tragus and just posterior to the external auditory meatus on the cavum conchae19 (Figure 2). For ear acupuncture and for the needling of Ting points (LI 1 on the index finger tip, ST 45 on 2nd toe tip), 15-mm plastic-handled Seirin needles were used. Ear tacks 1.5 mm long were placed on the 2 larynx points of both ears for 5 days after session 6.
All participants received exactly the same acupuncture treatment protocol in sessions 1 through 3. Beginning with session 4, the acupuncturists allowed each patient to provide some input as to the efficacy of the previous 2 sessions. For sessions 4-8, the use of either 15 Hz or 80 Hz stimulation frequency was determined by the participants’ individual input as to which of treatments 2 or 3 provided the better week-long improvement. In sessions 7 and 8, participants could choose between use of Ting points (from session 6) or body tonification points (from session 5), again according to their self-perception of improvement.
Participants showed significant improvement in some measures of vocal production and movement from outside to within normal range following treatment for many variables, even when statistically significant differences were not observed. Additionally, patients reported statistically significant improvements in their daily voice use on the Voice Handicap Index.
There was no value in use of the LU-LI Distinct Meridian treatment without electrical stimulation. Some participants were generally satisfied with the use of the Distinct Meridian; however, that was after at least 2 sessions that included electrical stimulation. Participants were equally likely to choose the 15-Hz or 80-Hz frequency setting for sessions 4-8.
Participants disliked the use of Ting points and did not feel they represented added value to the treatment; neither was there positive consensus about use of the body tonification points. Beginning with session 4, some individuals experienced reduction in vocal fold spasms with auricular stimulation at the French and Chinese “larynx” points. By the end of the study, the greatest improvements were noted when electrical stimulation was added to the Distinct Meridian treatment (session 2), and when the ear larynx points were stimulated (sessions 4 and 6). However, objective measures of voice production were more inconsistent in showing a positive response within 10 days after the protocol was completed.
On a post-treatment questionnaire, 7 of 10 participants reported improvement in their voices, and 2 others noted improvement during specific times in the protocol. Seven of 10 individuals rated their satisfaction with treatment for voice quality as a 3 or higher on a 5-point scale. Six rated as 3 or higher their feelings about amount of voice change. Seven stated that family members and friends noticed improvement, and 3 of the 7 who were employed said coworkers noticed improvement.
With its significant life effects, persons with SD are frequently desperate to receive treatment for their voice disorder. 20,21 Surgery on the vocal mechanism that will yield consistently good outcomes for persons with SD is still being investigated.12 The usual treatment available in larger medical centers, and sought by patients who must sometimes travel long distances to receive it, is botulinum toxin injections repeated every 2-12 months.7-9,12,13 An available alternative to botulinum toxin injections or a treatment that would extend the period between injections would be well received.
Therefore, we were hopeful to find which of several types of acupuncture could benefit persons with SD. We were aware of only 1 other published account of the use of acupuncture for a single patient with SD.15 The points used and treatment protocol were not identified in that study.
Our decision to use the LU-LI meridian was based on its trajectory and territory of influence that incorporates the trachea,vocal cords, and larynx.17 Use of the focusing point at ST 9 (Figure 1)
is an obvious choice for all laryngeal disorders. Use of ear acupuncture seemed reasonable because muscle sites represented on the ventral surface of the ear will readily relax with stimulation. The larynx points on the ear were commonly quite tender to touch and to needling, as typically occurs in auriculotherapy, in which a pathologic body part can appear to be “hot” in its corresponding ear representation.19 One of our consulting experts recommended use of the Ting points, but a limited trial at session 6 was not well received by our participants for subsequent sessions. Ting points are generally more useful for surface-level problems.19
We chose to use a standard protocol for each individual, allowing only a limited variation determined by participants’ input for the choice of frequency stimulation rate in the LU-LI meridian, and a variation on sessions 7 and 8 depending on the individual’s perception of better effects between sessions 5 and 6. Overall, each individual received generally the same treatment.
Individuals with previous botulinum toxin injections were allowed to participate because we believed that to have a sufficient sample size for our pilot study and for any future research on the use of acupuncture in SD, there was and will be a need to include individuals who have already had these injections.
Some participants reported week-to-week variation in the extent of improvement. The most dramatic and rapid laryngeal response to acupuncture was derived from bilateral needling of the larynx points on the inner surface of the tragus (Chinese larynx point), and the point 3 mm posterior to the external auditory meatus on the cavum conchae (French larynx point). One individual was speaking just as the ear larynx point was needled, and both he and the physician noted a dramatic change in vocal quality as the needle entered the point. The effect on that occasion lasted several days though the needle was removed after 60 minutes. Because of their awareness of the success of ear stimulation, some of our participants continued to use either a “pointer plus” 10-Hz ear point stimulator or a specially developed ear stimulator (provided by Dr Onje Erfan of Denver, Colo) that delivers electrical stimulation of several frequencies simultaneously. One month following the study, 5 of the individuals were self-stimulating the ear for their perceived improvements. At least 1 individual was still using ear stimulation bi-weekly 1 year later.
When asked to characterize their feelings about the effects of acupuncture in open-ended questions, a majority of study participants and frequently, their family members or coworkers, were positive. When asked to characterize the improvements, participants commonly described a reduction in the effort required to speak, and in perceived laryngeal tension while speaking. They commented that their voices, though still not normal, were more “functional” and could be “counted on.”
Future studies of the use of acupuncture for SD should consider scalp acupuncture and Koryo Hand acupuncture. There may be additional acupuncture programs derived from a Traditional Chinese Medicine (TCM) protocol that can be found through a Chinese literature search. A crossover design that uses different acupuncture methods would be beneficial, but a larger population will be needed to show significant differences. Finally, a trial that randomizes SD patients into either botulinum toxin injections or acupuncture treatment would be reasonable.
We undertook a pilot study to ascertain whether any of several standardized acupuncture treatments could ameliorate the vocal fold spasm and improve voice quality in persons with adductor SD. We found that a majority of our participants obtained subjective benefits in the ease of producing spontaneous speech through acupuncture treatment. The most useful approach included electrical stimulation with the LU-LI Distinct Meridian and auricular acupuncture on the larynx points. Further investigation of acupuncture for the treatment of adductor SD is warranted.
We sincerely thank Samantha Daughton, MA, Joseph Stemple, PhD, Barbara Weinrich, PhD, Tracy Miller-Seiler, MA, and Scott Goeller, MD, for their help in conducting this investigation. We also thank Susan Schmidt, PhD, and Aviva Scheer, PhD, for their editorial comments, and John Barrord, MD, for graphics work.
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Dr Steven Scheer’s specialties are Physical Medicine and Rehabilitation, Sleep Medicine, and Medical Acupuncture.
Steven Scheer, MD*
St Luke Hospitals
85 No Grand Ave
Fort Thomas, KY 41075
Linda Lee, PhD, is Professor and Graduate Program Director in the Department of Communication Sciences and Disorders at University of Cincinnati, Cincinnati, Ohio. She teaches and conducts research in the areas of voice disorders, craniofacial anomalies, and respiratory disorders.
Linda Lee, PhD
University of Cincinnati
Dept of Communication Sciences and Disorders
202 Goodman Ave
Cincinnati, OH 45267-0379