ABSTRACT
Vocal tremor is characterized by involuntary rhythmic modulations of pitch and loudness
and is best perceived during sustained phonation of vowels. It is most often present
in individuals affected by neurogenic disorders such as Parkinson's disease, amyotrophic
lateral sclerosis, spinal muscular dystrophy, spasmodic dysphonia, and essential tremor.
Vocal tremor does not appear to be responsive to systemic pharmaceutical management
but may benefit from injection of botulinum toxin (i.e., Botox) into affected musculature.
However, many individuals do not tolerate the potential side effects of severe breathiness
and difficulty swallowing associated with Botox injections. In this article, we summarize
the speech evaluation and treatment methods successfully used with an individual with
essential vocal tremor. Methods used for characterizing the individual's vocal tremor
patterns and the ensuing rationale for behavioral intervention is provided. The outcomes
of this case example motivated consideration of speech treatment as a beneficial strategy
for some individuals with vocal tremor.
KEYWORDS
Vocal tremor - voice disorder - voice treatment - voice evaluation - essential tremor
REFERENCES
- 1
Deuschl G, Bain P, Brin M. Ad Hoc Scientific Committee .
Consensus statement of the movement disorder society on tremor.
Mov Disord.
1998;
13
(Suppl 3)
2-23
- 2
Louis E D.
Clinical practice. Essential tremor.
N Engl J Med.
2001;
345
(12)
887-891
- 3
Sulica L, Louis E D.
Clinical characteristics of essential voice tremor: a study of 34 cases.
Laryngoscope.
2010;
120
(3)
516-528
- 4
Sirisena D, Williams D R.
My hands shake—classification and treatment of tremor.
Aust Fam Physician.
2009;
38
(9)
678-683
- 5
Elble R J.
Central mechanisms of tremor.
J Clin Neurophysiol.
1996;
13
(2)
133-144
- 6
Critchley M.
Observations on essential (heredofamial) tremor.
Brain.
1949;
72
(Pt 2)
113-139
- 7 Lee R G. The pathophysiology of essential tremor. In: Marsden C D, Fahn S, eds.
Movement Disorders. London, United Kingdom: Butterworths; 1987: 423-437
- 8
Pinto A D, Lang A E, Chen R.
The cerebellothalamocortical pathway in essential tremor.
Neurology.
2003;
60
(12)
1985-1987
- 9
Massey E W, Paulson G W.
Essential vocal tremor: clinical characteristics and response to therapy.
South Med J.
1985;
78
(3)
316-317
- 10
Louis E D, Vonsattel J PG, Honig L S, Ross G W, Lyons K E, Pahwa R.
Neuropathologic findings in essential tremor.
Neurology.
2006;
66
(11)
1756-1759
- 11
Louis E D, Ferreira J J.
How common is the most common adult movement disorder? Update on the worldwide prevalence
of essential tremor.
Mov Disord.
2010;
25
(5)
534-541
- 12
Rajput A H, Offord K P, Beard C M, Kurland L T.
Essential tremor in Rochester, Minnesota: a 45-year study.
J Neurol Neurosurg Psychiatry.
1984;
47
(5)
466-470
- 13
Chouinard S, Louis E D, Fahn S.
Agreement among movement disorder specialists on the clinical diagnosis of essential
tremor.
Mov Disord.
1997;
12
(6)
973-976
- 14
Tallón-Barranco A, Vázquez A, Javier Jiménez-Jiménez F et al.
Clinical features of essential tremor seen in neurology practice: a study of 357 patients.
Parkinsonism Relat Disord.
1997;
3
(4)
187-190
- 15
Lou J S, Jankovic J.
Essential tremor: clinical correlates in 350 patients.
Neurology.
1991;
41
(2 Pt 1)
234-238
- 16
Louis E D, Ottman R.
Study of possible factors associated with age of onset in essential tremor.
Mov Disord.
2006;
21
(11)
1980-1986
- 17
Louis E D, Ford B, Frucht S, Barnes L F, X-Tang M, Ottman R.
Risk of tremor and impairment from tremor in relatives of patients with essential
tremor: a community-based family study.
Ann Neurol.
2001;
49
(6)
761-769
- 18
Jankovic J.
Essential tremor: clinical characteristics.
Neurology.
2000;
54
(11 Suppl 4)
S21-S25
- 19
Chen J J, Swope D M.
Essential tremor.
J Pharm Pract.
2007;
20
(6)
458-468
- 20
Hachinski V C, Thomsen I V, Buch N H.
The nature of primary vocal tremor.
Can J Neurol Sci.
1975;
2
(3)
195-197
- 21
Bain P G, Findley L J, Thompson P D et al.
A study of hereditary essential tremor.
Brain.
1994;
117
(Pt 4)
805-824
- 22
Hubble J P, Busenbark K L, Pahwa R, Lyons K, Koller W C.
Clinical expression of essential tremor: effects of gender and age.
Mov Disord.
1997;
12
(6)
969-972
- 23
Brown J R, Simonson J.
Organic voice tremor. A tremor of phonation.
Neurology.
1963;
13
520-525
- 24
Koller W C, Busenbark K, Miner K. Essential Tremor Study Group .
The relationship of essential tremor to other movement disorders: report on 678 patients.
Ann Neurol.
1994;
35
(6)
717-723
- 25
Warrick P, Dromey C, Irish J, Durkin L.
The treatment of essential voice tremor with botulinum toxin A: a longitudinal case
report.
J Voice.
2000;
14
(3)
410-421
- 26
Warrick P, Dromey C, Irish J C, Durkin L, Pakiam A, Lang A.
Botulinum toxin for essential tremor of the voice with multiple anatomical sites of
tremor: a crossover design study of unilateral versus bilateral injection.
Laryngoscope.
2000;
110
(8)
1366-1374
- 27
Dromey C, Warrick P, Irish J.
The influence of pitch and loudness changes on the acoustics of vocal tremor.
J Speech Lang Hear Res.
2002;
45
(5)
879-890
- 28
Koda J, Ludlow C L.
An evaluation of laryngeal muscle activation in patients with voice tremor.
Otolaryngol Head Neck Surg.
1992;
107
(5)
684-696
- 29
Finnegan E M, Luschei E S, Gordon J D, Barkmeier J M, Hoffman H T.
Increased stability of airflow following botulinum toxin injection.
Laryngoscope.
1999;
109
(8)
1300-1306
- 30
Shipp T, Izdebski K.
Current evidence for the existence of laryngeal macrotremor and microtremor.
J Forensic Sci.
1981;
26
(3)
501-505
- 31
Bové M, Daamen N, Rosen C, Wang C C, Sulica L, Gartner-Schmidt J.
Development and validation of the vocal tremor scoring system.
Laryngoscope.
2006;
116
(9)
1662-1667
- 32
Gonzalez-Alegre P, Kelkar P, Rodnitzky R L.
Isolated high-frequency jaw tremor relieved by botulinum toxin injections.
Mov Disord.
2006;
21
(7)
1049-1050
- 33
Tomoda H, Shibasaki H, Kuroda Y, Shin T.
Voice tremor: dysregulation of voluntary expiratory muscles.
Neurology.
1987;
37
(1)
117-122
- 34
Gamboa J, Jiménez-Jiménez F J, Nieto A et al.
Acoustic voice analysis in patients with essential tremor.
J Voice.
1998;
12
(4)
444-452
- 35
Ludlow C L, Bassich C J, Connor N P, Coulter D C.
Phonatory characteristics of vocal fold tremor.
J Phonetics.
1986;
14
509-515
- 36
Ramig L A, Shipp T.
Comparative measures of vocal tremor and vocal vibrato.
J Voice.
1987;
1
162-167
- 37
Barkmeier J M, Case J L, Ludlow C L.
Identification of symptoms for spasmodic dysphonia and vocal tremor: a comparison
of expert and nonexpert judges.
J Commun Disord.
2001;
34
(1-2)
21-37
- 38 Ludlow L. Management of the spasmodic dysphonias. In: Rubin J S, Sataloff R I,
Korovin G, eds. et al. Diagnosis and Treatment of Voice Disorders. New York, NY:
Igaku-Shoin; 1995: 436-454
- 39
Lundy D S, Roy S, Xue J W, Casiano R R, Jassir D.
Spastic/spasmodic vs. tremulous vocal quality: motor speech profile analysis.
J Voice.
2004;
18
(1)
146-152
- 40
Koller W C, Graner D, Mlcoch A.
Essential voice tremor: treatment with propranolol.
Neurology.
1985;
35
(1)
106-108
- 44
Limousin P, Speelman J D, Gielen F, Janssens M.
Multicentre European study of thalamic stimulation in parkinsonian and essential tremor.
J Neurol Neurosurg Psychiatry.
1999;
66
(3)
289-296
- 41
Brin M F, Lyons K E, Doucette J et al.
A randomized, double masked, controlled trial of botulinum toxin type A in essential
hand tremor.
Neurology.
2001;
56
(11)
1523-1528
- 42
Jankovic J, Schwartz K, Clemence W, Aswad A, Mordaunt J.
A randomized, double-blind, placebo-controlled study to evaluate botulinum toxin type
A in essential hand tremor.
Mov Disord.
1996;
11
(3)
250-256
- 43
Carpenter M A, Pahwa R, Miyawaki K L, Wilkinson S B, Searl J P, Koller W C.
Reduction in voice tremor under thalamic stimulation.
Neurology.
1998;
50
(3)
796-798
- 45
Koller W C, Glatt S, Biary N, Rubino F A.
Essential tremor variants: effect of treatment.
Clin Neuropharmacol.
1987;
10
(4)
342-350
- 46
Moringlane J R, Pützer M, Barry W J.
Bilateral high-frequency electrical impulses to the thalamus reduce voice tremor:
acoustic and electroglottographic analysis. A case report.
Eur Arch Otorhinolaryngol.
2004;
261
(6)
334-336
- 47
Sataloff R T, Heuer R J, Munz M, Yoon M S, Spiegel J R.
Vocal tremor reduction with deep brain stimulation: a preliminary report.
J Voice.
2002;
16
(1)
132-135
- 48
Adler C H, Bansberg S F, Hentz J G et al.
Botulinum toxin type A for treating voice tremor.
Arch Neurol.
2004;
61
(9)
1416-1420
- 49
Hertegård S, Granqvist S, Lindestad P A.
Botulinum toxin injections for essential voice tremor.
Ann Otol Rhinol Laryngol.
2000;
109
(2)
204-209
- 50 Titze I. Workshop on acoustic voice analysis. National Center for Voice and Speech
February 17–18, 1994 Iowa City, IA;
- 51 Boersma P, Weenink E. Praat: doing phonetics by computer (Version 5.1.05) [Computer
program] 2010. Available at: http://www.praat.org/ Accessed June 4, 2010
- 52
Qi Y, Hillman R E, Milstein C.
The estimation of signal-to-noise ratio in continuous speech for disordered voices.
J Acoust Soc Am.
1999;
105
(4)
2532-2535
- 53
Horii Y, Hata K.
A note on phase relationships between frequency and amplitude modulations in vocal
vibrato.
Folia Phoniatr (Basel).
1988;
40
(6)
303-311
- 54
Farinella K A, Hixon T J, Hoit J D, Story B H, Jones P A.
Listener perception of respiratory-induced voice tremor.
Am J Speech Lang Pathol.
2006;
15
(1)
72-84
- 55
Titze I R.
On the relation between subglottal pressure and fundamental frequency in phonation.
J Acoust Soc Am.
1989;
85
(2)
901-906
- 56 Boone D R, MacFarlane S C. The Voice and Voice Therapy. 5th Ed. Mahwah, NJ: Prentice
Hall; 1994
- 57 Glenn E, Glenn P, Forman S. Your Voice and Articulation. Mahwah, NJ: Prentice-Hall;
1989
Julie Barkmeier-KraemerPh.D. CCC-SLP
Department of Speech, Language, and Hearing Sciences, University of Arizona
1131 E. 2nd Street, P.O. Box 210071, Tucson, AZ 85721
Email: jbark@u.arizona.edu
