Singers with disabilities are nothing new. In fact, they are heard frequently on stage. Consider Thomas Quasthoff, a victim of thalidomide, or Irene Gubrud, whose legs have been partially paralyzed since childhood from a carnival ride accident and so she uses a crutch—just to name two world-class classical singing artists with disabilities.
Some singers have experienced vocal abuse and even damage due to constant teaching, lack of proper hydration, or vocal misuse. Increasingly prevalent, however, are singers who have suffered some sort of brain injury or stroke. Some injuries and their rehabilitation have been investigated scientifically and reported in periodicals such as the Journal of Voice. I speak 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 the benefit of a regular otolaryngologist.
Fourteen years ago I had a stroke. Fortunately, my stroke was relatively mild and I have now regained nearly all my vocal facility. It has not been easy, however, nor without frustration. Further, my journey to regain my voice has also had a great effect on my work as a singer and a voice pedagogue.
Stroke: A Brief Description
Brain attack or cerebrovascular accident are terms frequently used in describing a stroke. A blood clot develops in the brain, or a vessel weakens or breaks, causing blood loss to that area, which can destroy vital nerves controlling other parts of the body. My stroke—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 left me with numbness on the right side. Over the 14 years since my stroke, I have regained much function, except for some of the fine motor skills of my right hand.
Right after my stroke, I experienced some vocal fold paresis (slight weakening of one side of the vocal folds). As a singer and voice teacher, this is what was most frustrating to me. It also required the most attention and creativity in developing my own methods of rehabilitation, both in speaking (with the assistance of an SLP) and singing (developed mostly on my own, from traditional vocalises with the aid of a sensitive singing teacher, Donna Harler-Smith, with whom I studied from 1998-2005).
There are different gradations and types of cerebrovascular events. My problem might not be the same as another individual’s as each case is unique. Traditional therapy for stroke focuses on 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 U.S., which often pay only for what is needed to return a person to basic functioning skills. Traditional therapy is mainly available to those who live in or near large population centers with a base of well-trained specialists in voice therapy.
Thus, I had to design my own rehabilitation as a singer because of my health insurance—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. This may change somewhat with the Affordable Care Act, although its future is uncertain as of press time.
My stroke was on June 27, 1998. I gradually became aware that I had difficulty signing my name throughout the day and I felt exhausted. In retrospect, the stroke probably happened during the night. I drove myself (not recommended) to the emergency room, where I was hospitalized for five days, having CAT scans, MRIs which confirmed the ischemia, and heart blockage tests (negative).
Following my five-day stay at a conventional hospital, I was transferred to a rehabilitation hospital, where I spent another seven intensive days in therapy. I then continued outpatient therapy for another three months. In the conventional hospital, I became aware of numbness in my right hand, arm, and right leg and some sluggishness of speech, droopiness of the right side of my mouth, and some difficulty in singing. Later, when I was more cognizant, I also noticed some slight vocal fold paresis.
For the first week as an inpatient in the rehabilitation hospital, I concentrated on basic function—standing, walking, and just moving my right arm and hand. Primarily, I had guidance, not assistance, from the therapists and nurses as I slowly worked for recovery. But more important questions for myself as a singer began to arise. What was my vocal function? Would I be able to sing normally? If so, how long would rehabilitation take? And how could I cope with the rehabilitation of the voice through all of this? As might be imagined, I experienced some depression as I contemplated my future.
Inpatient 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. Re-establishing brain connections or developing alternative neuropathic roots for those connections takes time and can be very frustrating. In addition, simply because of the stroke and brain trauma themselves, I tired much more easily. My inpatient therapy included the following exercises.
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. I followed this with push-ups, free weights, and resistance weights. Fine motor skill exercises included grip strength, grasping, reaching, keyboarding, and writing.
Speech therapy
Fortunately, I had only extremely mild aphasia. About a week into my inpatient rehabilitation, I was assigned a speech therapist for three one-hour sessions per week, upon my request, plus given exercises to do on my own. 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. I practiced the following two to three times per day: tongue consonants followed by vowels, especially l, n, t, d, followed by [i], [e]; and words and sentences, selected by an SLP.1 I eventually went through the entire book Diction by John Moriarty over the course of a year, systematically repeating the book several times. This helped me to further relearn my skills on vowel and consonant combinations in a variety of languages.
Lip and mouth range of motion (without speaking)
You may have seen noted actor Kirk Douglas demonstrate these some time ago in his ads for stroke prevention. These involve pursing and extending the lips, without speaking. However, this has since fallen out of favor for more holistic and integrated speech therapy.
A Singer’s Rehabilitation
Once I got over my initial depression, I took a very proactive approach to therapy in general. I began to develop rehabilitation exercises of my own.
The use of falsetto was important for my vocal rehabilitation, especially extending it downward and “blending in” for head voice. I also used 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. I gradually added exercises opening the lip trill into a vowel [u], [o], [a], [e], [i], descending over a fifth, and then the entire vowel spectrum. Throughout these exercises, I strove to maintain a steady stream of breath. (See below.)
After about a month, I added phrases and slow, short songs (especially Alessandro Scarlatti), concentrating on vowel alone and vowel plus consonants. Mixed vowels in German and French still required more work. It was difficult to roll an “r” and pronounce combinations of two consonants due to a feeling of tongue thickness. This got better over several months, and soon I could speak much faster.
I still use these exercises even though it has been years since my stroke. They are a part of my everyday vocalization, I also use some of them with students, for varied purposes, and as a foundation in vocal study.
Other Adverse Affects
At first, breathing was more difficult and came in shorter bursts owing to the slight vocal fold paresis and the greater effort. I noticed a tendency to overdo subglottic pressure 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.
Because I was now on a diuretic, additional medication to control blood pressure, and blood thinners (first aspirin and then Plavix), hydration especially was now an issue. To avoid “dry mouth,” I needed to drink a lot of extra water. I also had to take care in approaching higher, louder pitches to avoid vocal fold damage. I do not do as much intense upper tessitura singing now.
Performing Again
Approximately nine months after my stroke, I gave a public recital consisting of 14 songs in Italian, French, German, and English. Nine of the songs were new; five I had previously performed. While it was important to learn new material, having some familiar repertoire to which I could attach muscle memory was crucial.
Almost 10 months after my stroke, I performed the tenor solos in Orff’s Carmina burana with orchestra. This was actually helpful in my recovery, especially for use of head and mixed voice since the tessitura is quite high.
Additional Thoughts
Others who have had strokes have varied situations, different from mine. Some recover quickly, with little aftereffect. Others have debilitating paralysis, a paralyzed vocal fold or, worse, never recover full functionality even with therapy. The biggest thing for me was that what I once did automatically I now had to govern by overly conscious thought for over a year or even longer. It was like being a child again or a beginning voice student. My speech, singing, and movement were very calculated and somewhat devoid of spontaneity, though that has gradually improved to former levels after 14 years.
As I mentioned, I had to make adjustments in my mental attitude. This is an ongoing process. At times I become frustrated about what I can do versus what I once was able to do. Sometimes this leads to borderline depression. I do my vocal rehabilitation exercises to help overcome this. My voice has returned to normal, especially to others’ perceptions. I no longer do “patter” songs, however, and other fast diction pieces.
I have recently become a member of the Classical Musicians with Disabilities discussion group (classmusdis@googlegroups.com) led by Vivian Conejero. This is a great resource for singers and other musicians with a variety of disabilities, not just stroke-related issues. Conejero founded the D Major International Music Festival which produces performance opportunities for classical singers and instrumentalists with disabilities. (Learn more at dmimf-classical.webs.com.)
As a voice teacher, I had been a decent “utility” pianist, and was a keyboard minor as both an undergraduate and master’s 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 I just play the chord structure, having them figure out where they are in relation to the chords. I also use CD accompaniments that come with certain books (something I swore I would never do) and now I am trying to master the nuances of a recently acquired Yamaha Disklavier so that I can further assist my students.
Since my stroke, I exercise regularly, including walking and bicycling for at least an hour nearly every day—except in inclement weather, when I use an old NordicTrack ski machine. I continue to have hydration issues, especially now in the desert air of southwest Texas. I strive to keep hydrated.
Conclusion
As a result of my stroke, I have made changes in vocal pedagogy for both myself and my students. I now give greater emphasis on spinal alignment and body mapping. I put more emphasis on breath flow, legato (lip trill, raspberry), and vocal ease. I focus more on student-centered pedagogy and musicianship. It has also affected the literature I assign—there is sometimes a conflict over what I can play/fake at the piano versus what is best for my student.
I am still teaching and performing and I owe my recovery to the Nebraska farm work ethic and perseverance of my late my parents, Donald W. and Mary Louise Callen Freed; to my voice teacher, Donna Harler-Smith of the University of Nebraska–Lincoln; to the noted teacher, Thomas Houser; and to my students.
Endnotes
1. Sataloff, Robert T. Treatment of Voice Disorders. San Diego: Plural Publishing, 2005, pp. 385-387.
