Section 11 - Using Auditory Feedback in Clinical Settings

An essential part of the treatment process for communication disorders is feedback to the patient, particularly auditory feedback. As presented in Section 4, most patients lack good tactual or proprioceptive feedback specific to speech or voice production. Consequently, they rely much on auditory feedback. The Kay Facilitator, Model 3500, provides both enhanced and degraded auditory feedback. Most children and adults profit from forms of enhanced auditory feedback (real-time amplification, looping playback of what was just said, or coupling real-time amplification with the beats of a metronome). Speech and voice in some patients are improved under conditions of degraded auditory feedback (preventing the patient from experiencing normal auditory feedback by introducing delayed auditory feedback [DAF] or speech-range masking).

There are five auditory feedback modes available on the Kay Facilitator, Model 3500:

1. Real-time amplification;

2. Looping playback of what was just said;

3. Delayed auditory feedback;

4. Speech-range masking;

5. Metronome pacing clicks.

The real-time amplification mode may be used alone or in combination with any one of the other four feedback modes. In the clinic or office situation, the clinician will use the instrument in a fixed position (not worn as an ambulatory aid) . The Facilitator is plugged in to a power source, enabling the speech-language pathologist (SLP) to also jack into the instrument his or her own headset and microphone. The patient also wears a headset and mike. In the fixed clinic situation, the clinician can also control loop feedback, presenting the patient a loop model of a target word-phrase-sentence that can be repeated one time or indefinitely (as long as the clinician keeps pressing the PLAY button).

The Kay Facilitator is designed to be used in different ways in clinic situations:

1. Diagnostically;

2. In direct therapy;

3. As a portable communication aid.

For each of these three uses, we will consider the use of the instrument with particular patient groups, describing particular application guidelines.

The Facilitator as a Diagnostic Tool in the Clinic

Any one of the five auditory feedback modes may be selected for diagnostic use. For example, articulation or voice testing might be used to determine if there are changes (positive or negative) in the patient’s speech-voice production in the presence of amplification. Or, in language testing, such as looking at auditory memory span, one might present varying lengths of utterances by varying the length of playback loops. Similarly, in stuttering, there are often measurable effects of using either DAF or metronomic pacing on the speech fluency of stutterers. Also, any alteration of auditory feedback may influence the fluency patterns of patients with dysarthria, apraxia of speech, or nonfluent aphasia.

Using the Facilitator diagnostically will not usually add extra time to the diagnostic session. The clinician continues to use the evaluative tasks and tests required for the diagnostic evaluation of the particular clinical problem. When patient response is tested, selected feedback modes are added to the presentation. For example, the patient with a voice problem may be examined by videostroboscopy; the view of the larynx can be contrasted under two conditions, without auditory feedback and with the addition of masking. Is there a contrast in laryngeal physiology under these two conditions, one with competing masking noise and one without it? Under conditions of masking, some patients with functional voice disorders seem to produce louder, less dysphonic voices. Would such a finding be useful at the time of initial evaluation?

Using the headings from Table 2-1, we will consider the diagnostic use of the Kay Facilitator with various communication disorder problems in the clinic:

Child Articulation. Much of phonologic remediation uses auditory presentations in therapy. In the diagnostic sessions that precede therapy, the child’s ability to repeat a sound or word may be enhanced by real-time amplification. The Facilitator offers real-time, focused speech amplification. Or, stimulability testing finds if the child has the capability of correct production if the target sound (or word) is modeled visually and auditorily. Perhaps the clinician introduces looping. Using the external controls on the looping unit, sounds and words that the child produces may be captured for immediate or continuous playback. If the child’s production is captured on loop, can he modify his production to match the spoken target?

Dysarthria. In the diagnostic evaluation of children and adults with dysarthria, some of our feedback modes may be facilitative for better speech and improved prosody. Articulation in motor speech disorders (found in such problems as muscular dystrophy, cerebral palsy, multiple sclerosis, amyotrophic lateral sclerosis, Parkinson’s disease, etc.) is sometimes improved in precision and clarity with real-time amplification, masking, or metronomic pacing. The patient’s articulatory response should be measured without feedback and then with a particular mode; if a particular mode is found facilitative, that mode (such as masking) could be used in therapy. Using loop playback diagnostically is helpful in determining if phonologic production can be improved in patients who listen critically to immediate playback of their own speech.

Voice Disorders. In patients with voice disorders, the sound of voice can often be improved by using either enhanced or degraded auditory feedback. Diagnostically in a voice evaluation, we determine the effects of enhancing feedback by using real-time amplification. As we evaluate patients, they wear headphones jacked into the Facilitator. Does hearing amplified voice improve phonation? Or we present delayed loop presentations of the voice directly back to the patient. Can voice production be changed by listening critically to loop playback? Some dysphonias are lessened by degrading the patient’s auditory feedback through DAF or masking; this should be determined in early diagnostic sessions in the clinic. For some patients with weak voices or aphonia, speech-range masking can often facilitate a good voice. As part of the voice diagnostic session, this good voice could then be captured on loop playback, with the SLP determining if the patient can maintain the better voice without the need of the masking.

Stuttering. In the clinical evaluation of the child and adult who stutter, the Facilitator offers the SLP several auditory feedback features that can assist diagnostically. Amplification of what the stuttering patient says is sometimes facilitative in producing more fluent speech. In the evaluation of teenagers and adults who stutter, we sometimes find increasing the loudness of their speech as a reflexive-reaction to real-time amplification improves fluency. The diagnostic session might also test the patient under conditions of delayed auditory feedback and speech-range masking to determine if such interferences to normal auditory feedback improve speech fluency. Some stutterers and some patients with very rapid speech, such as in cluttering, could be tested using the metronomic pacer on the Facilitator to determine if forcing a change of rate of speech influences overall fluency.

Aphasia. Adding auditory feedback to aphasia testing will sometimes facilitate better patient response. Historically, much emphasis was given to determining the aphasic patient’s "reauditorization" abilities, i.e., the ability to retain what was said by others and the patient’s ability to remember the order of words he or she wishes to say. Part of the aphasia evaluation should include information on patient response (spoken, written, pointing} when incoming auditory stimuli are amplified. The delayed loop playback can often increase the patient’s reauditorization, producing improved performance during testing. The SLP may wish to test the patient’s spoken response under conditions of masking. It could also be determined at the time of testing if the nonfluent aphasic patient, who often has an associated oral apraxia, may profit from metronomic pacing.

Adult Right Hemisphere. There has been continuing evidence that patients with right-hemisphere damage often display deficits in visual perception. It is believed that such patients often use the auditory system to compensate for their visual confusions. The influence of auditory feedback input should be determined during the initial evaluation. Does the patient’s overall response to testing of various modalities improve with bilateral amplification, as provided by the Facilitator? Does a captured auditory stimulus, such as heard several times on the loop feedback, seem to facilitate response? Finally, it can be determined if metronomic pacing will enhance the attention span and response accuracy of the patient with right-hemisphere damage.

The Facilitator as a Therapy Tool in the Clinic

The versatility of the Facilitator with its five auditory feedback modes makes it a versatile clinical instrument with both children and adults. Just turning the power on the Facilitator presents focused, real-time amplification of both the clinician’s and the patient’s speech and voice.

The remote loop playback switches permit the clinician to playback clinician or patient utterances by pressing the STOP/PLAY button. The length of the playback is controlled by the clinician, from 2–6.5 secs, starting or stopping it at any time. The other Facilitator features (DAF, masking, or metronomic pacing) may be selected by turning the MODE switch to the desired component (as visualized in the mode-display window).

A useful way to describe the use of the Facilitator in clinic therapy is perhaps seen in each of the following case histories representing a particular patient group.

Articulation, Jamie, age 7. Jamie attended second grade in a parochial school and was referred to the clinic for markedly delayed phonologic development. While his overall language scores in listening and reading comprehension were within normal limits, his articulation was seriously compromised, resulting in most of his age peers and the adults in his life being unable to understand what he said. Individual speech therapy, using the phonological process model proposed by Hodson (1986), demanded that therapy "bombard" Jamie with auditory focus on his target sounds. The SLP used the focused speech amplification of the Facilitator, with Jamie listening closely to both the clinician’s and his own articulatory productions. Of special value was listening to loop playback of his own articulatory attempts. Jamie would repeat a word containing the target speech sound several times on the loop and then listen critically to the immediate playback. Most of his therapy time was spent using the auditory modeling of real-time amplification and delayed loop auditory feedback, with accelerated positive results.

Dysarthria, Mr. P., age 69. Mr. P. had been an insurance salesperson for most of his adult life, until progressive symptoms of Parkinson’s disease forced him to retire. After his clinic evaluation, it was found that he had a seven-year history of Parkinson’s, recently controlled somewhat by L-Dopa medication. His dysarthric speech was characterized by "accelerated rate, with light, barely audible voice." Two features of the Facilitator were used effectively, producing an immediate increase in overall speech intelligibility: speech range masking and metronomic pacing. Using increased levels of masking, his speech intelligibility and voice loudness increased. Masking coupled with pacing set near the middle of the pace range, approximately 100 beats per minute, seemed to slow down his speech rate. Of some interest here was that listening to the metronome beats alone with very little amplification, not only slowed down his speaking rate but increased the loudness of his voice as well.

Voice disorders, Anna, age 9. Anna was referred to the voice clinic by her school SLP because "after working several months with us on her vocal nodules, she lost her voice completely." Laryngoscopic examination found Anna to have a normal larynx, free of any structural problem, such as the nodules that had previously been there. Masking was used, using the Lombard-method described in Section 4. She was asked to put on the Facilitator headphones and use the lapel mike. Then she was asked to read aloud, which she did in a completely aphonic whisper. About 30 words into the whisper reading, the SLP turned on mid-volume speech-range masking. Under the masking condition, a light phonation was heard. This light voice was recorded on a cassette recorder. The masking was then increased in intensity, and her voice got louder. She could tell she was using voice, and the SLP asked her to remove the headphones.

She appeared thrilled that she was able to produce voice again. At this point, we were able to use successfully the direct, symptomatic therapy for aphonia as described by Case (1996) and Boone and McFarlane (1994).

Stuttering, Kevin, age 15. As a sophomore in high school, Kevin was experiencing an increase in stuttering symptoms. He was referred by his parents for therapy for his stuttering. His dysfluency was characterized by mouth pursing and slight prolongation of initial sounds, usually limited to the beginning of a phrase or sentence or words beginning with vowels. He felt that his speech was best at school and worst at home where he had to deal with an older brother who continually taunted him. On oral reading using a metronome to slow down his rate of speech, there was no evidence of stuttering. Consequently, in the beginning of therapy, we used oral reading with metronomic pacing to establish the patterns of easy speech fluency. We also found that under conditions of DAF, he experienced very little stuttering. Both metronomic pacing and DAF were used to reinforce the feeling of good, easy onset (normal) speech. At the present time, Kevin’s speech therapy continues with present efforts directed toward developing easy onset, "left to right" continuing airflow speech without using any of the auditory feedback modes of the Facilitator.

Aphasia, Muriel, age 72. Two years previously, Muriel had a left CVA that left her with a profound right hemiplegia and a severe motor aphasia. After one year, she had almost no spontaneous speech. A therapy program was designed that offered the patient and her husband some psychological support, along with a few specific speech therapy tasks to do at home. The patient was seen once weekly in the clinic for speech-language therapy. It developed in therapy that her most severe deficit was an almost total visual agnosia that prevented her from identifying actual items (when she did not hold or touch them) or objects in pictures. One day, the SLP used speech-range masking with Muriel, and when she "couldn’t hear herself talk" there was an amazing increase in word recall and sentence formulation (there was no change in her poor visual recognition). However, she began wearing the portable Facilitator at home with the masking mode set moderately high; her husband reported a noticeable increase in the relevance and accuracy of what she said under the condition of masking. Furthermore, in the past six months she has made surprising gains (she was now 18 months plus since onset of her CVA) in her ability to recall words and formulate more elaborate sentences.

Right hemisphere damage, Paul, age 29. Paul experienced right hemisphere damage in a one-car automobile accident. When he was first seen in the speech clinic he appeared easily distracted. He had difficulty sticking to a task and was particularly stymied now and then by his visual perceptual confusions. When he could not figure something out, he would quickly change the activity and generate irrelevant verbal responses. We found the loop playback on the Facilitator to have a positive influence on Paul’s ability to concentrate on a single task. The SLP would give Paul 15- to 20-word sentences to repeat after her; he frequently needed to hear the loop repetition of the sentences several times before he could repeat them back correctly. It was the sticking with the task aspect of the activity and his eventual success in repeating, that made early therapy a success for Paul. From listening to long sentences and being asked to repeat them, he went on to minimizing his visuo-spatial problems and developing appropriate language pragmatics. During much of his language therapy, Paul wore headphones and seemed to profit from real-time amplification.

The Facilitator as a Portable Communication Aid

The positive changes in communication facilitated in the clinic need to be transferred with the patient out of the clinic. The clinic version of the Facilitator with its clinician’s mike and headphones, plus looping controls, can be unplugged and travel with the patient as a portable, battery-powered unit. The mode button is pressed to access the desired auditory feedback mode. The patient wears the Facilitator in a waist-pack. The patients will use the Facilitator in practicing the appropriate exercises set up by the SLP, or the patients will use it as a portable communication aid to be worn in any situation they find useful.

Although each of the auditory feedback components have been described separately in Sections 5-10 of this manual, we will look at each one separately when the Facilitator is used as a portable communication aid.

Amplification. The amplification component on the Facilitator is basically designed for enhancing the patient’s own speech/voice and not designed for listening to other people speak, or to music, and to other environmental sounds. The Facilitator is not a hearing aid. Rather, it is designed with a 70–7800 Hz speech-range focus to enhance listening to one’s own voice and speech.

Patients with voice disorders, some patients with dysarthria, and some stutterers will demonstrate improved communication as they listen to their own amplified speech/voice. As long as they speak while receiving Facilitator amplification, they will sound better.

Masking. There is a federal judge who is known for his tendency to mumble. His primary complaint in our clinic was that occasionally people could not understand him. His mumbling was corrected by the voice-activated masking he hears on the Facilitator. Under conditions of masking, his articulation sharpens and his voice is louder. Wearing a portable masking device and receiving speech-range masking will often help selected patients speak better. Another example of masking was seen in a young woman with a weak voice following a head injury; she turns on continuous masking whenever she is in a situation where she needs to be heard. When not in a talking situation, she does not wear the Facilitator.

Delayed Auditory Feedback. A 39-year old biology teacher lectures his high school classes using DAF, wearing a Facilitator in the waist-pack, complete with earphones and lapel microphone. His students know that he would stutter without the DAF and are very accepting that he wear the Facilitator. Kevin, the boy who stutters (described on a previous page) uses the DAF mode on the Facilitator for oral reading in his home practice sessions; using the DAF in practice gives him the experience and feeling of normal speech as he reads. He does not wear the unit to school, where he is already fluent.

Metronomic Pacing. Patients who have found the metronome useful in the speech clinic will often use it as a practice device at home or as a way of facilitating fluency at work. The patient, usually someone with dysarthria or who stutters, will often increase speech fluency by altering their speech rate (slower or faster) using a metronome. The portability of the Facilitator, that requires wearing only the earphones while using the pacer, makes it a useful device for patients requiring rate-direction in various everyday situations.

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Boone, D.R. and McFarlane, S.C. (1994). The Voice and Voice Therapy, 5th Ed. Englewood Cliffs, NJ: Prentice Hall.

Case, J.L. (1996). Clinical Management of Voice Disorders, 3rd Ed. Austin, TX: Pro-Ed.

Hodson, B.W. (1986). The Assessment of Phonological Processes, Revised. Austin, TX: Pro-Ed.

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