Web Posted on: December 31, 1998

Visivox- An objective monitor of speech volume. A practical application of the Visivox for self-monitoring of speech volume in the acquired brain injured population

George Whitmore, MA
Speech Pathologist at Casa Colina Centers for Rehabilitative Medicine
Transitional Living Center
Pomona Campus

When working with the brain injured population, I found that I was often in need of an objective measurement to give continuous feedback to clients about the degree of their volume. This measurement needed to be objective and not subjective, as well as being continuous without the need to interrupt the client's responses with verbal feedback. The augmentative device used at Casa Colina to provide that feedback is the Visivox. The Visivox provides objective, on-going feedback. It eliminates the inconsistent and often subtle errors that are inherent with therapist feedback. It also empowers the client with positive control over their speech volume, and encourages them to be independent.

When choosing an augmentative device, that device had to be able to be utilized by the populations served at the variety of programs on the Casa Colina campus. Casa Colina provides services to the adult brain injured (TLC), children, in-patient, out-patient, Adult Day Health Care (ADHC), Horticulture and Perform programs.

The Visivox was originally conceived as a tool to assist public speakers monitor their speaking volume so they can be heard by their audience. Teachers, preachers, seminar leaders, trainers, debating societies, etc., all have purchased and found this tool to be exceptionally valuable in making a well presented program. In a therapy setting the Visivox is used as a tool to assist clients in monitoring speech volume in group as well as in individual settings.

SET UP

The first thing in set up is to make sure that the battery is fully charged. The directions state that the battery is good for up to a minimum of thirty (30) hours, and that a light will go on when the battery is low. After checking the battery by looking for the low battery light, one opens the case and takes out the light bar and the external microphone (if the box is able to be close enough to the speaker, the internal microphone will perform well) and then close the box. All receptacles are clearly identified and are visually very different making it easy to put the cords in the right places. Plug the light bar cord into the large matching plug receptacle, aligning the white lines on the top of both the plug and receptacle. Plug in the microphone (if you are using one). Place the microphone cable in the clasp attached to the light bar and place the light bar where it can easily be seen by the speaker. Flip on the toggle switch (it's lighted, so it is easy to know when it is on.) One next adjusts the potentiometer knob to exclude extraneous room noises (like the humming of fluorescent bulbs). The light bar will now show no lights. The only light that shows is when the speaker speaks. The light bar display is green in the middle and progresses to red at the edges. A soft sound will show in the middle of the light bar as a small green light. As the volume increases the light bar increases the number of lights lit and spreads out from the center toward both sides equally until the red area is lit and at maximum noise the entire light bar is alight. The readout then show the graduated increase in sound by an increasing amount of lit bar. The user just has to establish how many bars he wants lit and maintain that volume to keep the light bar in that range.

Target Population

The target population for this article was located at the Casa Colina Center For Rehabilitation's Transitional Living Center, and were clients in the acquired brain injured program. The population fluctuates in ages from age 15 to 90. The program at LTC is a comprehensive, trans-disciplinary program. All compensatory and augmentative strategies are designed to be easily utilized by the other disciplines.

Case Studies

Mike M. Mike, age 32, was married and had 4 children. While at work he suffered a brain injury as a result of a fall from a fork lift. His medical course was listed as "rocky" with multiple medical problems including: seizures, hyper/hypothermia, thrombocytopenia, and s/p deep vein thrombosis.

Upon assessment of his speech and voice, it was noted that he had severe decreases in the ability to control his oral-motor movements, with decreased ROM, severely decreased oral motor strength, and his right side weaker than this left. Volume was severely decreased, making him audible only to people very close to him (within 2 feet.) He also demonstrated insufficient breath support and control to sustain a tone for more than 1-2 seconds. The tone was noted to be very breathy. He was unable to make accurate judgements of the degree of loudness.

Following a therapeutic course to strengthen his oral motor mechanism and to increase his breath control to sustain a vocal tone to 12 seconds, he was introduced to the Visivox. Initially, he needed maximal cues to observe the visual light bar at the same time he was speaking. As the course of therapy progressed, he was able to decrease the amount of cuing to minimal levels. Initially, the client could not project his voice to be heard at a distance of 2-3 feet. He has since progressed to where he can project to a listener at a distance of 20 feet consistently. He is accurate when describing his volume levels. He is consistent at maintaining the correct volume for the situation.

Jim C. Jim is a 51 year old man who suffered a brain injury as a result of a fall from a horse. A CT scan at the time of the accident showed a basilar skull fracture, right temporal contusion and subarachnoid hemorrhage. He also had a facial x-ray that revealed anterior maxillary wall fracture, and orbital blow out fracture. He was intubated and had a tracheostomy.

At the initial evaluation, it was noted that Jim was disoriented, confused and aphonic. He demonstrated decreased oral motor strength, ROM, and apraxic-like motor planning skills. His tongue was asymmetrical with the left noticeably smaller than the right. He was unable to hold a diadochokinetic pattern. He was able to generate a short tone at a very decreased volume with max cuing, and was unable to make any pitch changes. His attention was severely decreased.

Following a therapeutic course to strengthen his oral mechanism and to increase his breath control to sustain a vocal tone to 12 seconds, he was introduced to the Visivox. He was able to quickly learn to watch the light bar as he was vocalizing, and was able to increase his volume from a bare whisper, to voicing loud enough to be comfortably heard at ten feet. Currently, (he is still a patient in our facility, and his course of therapy is not yet completed) he needs moderate cuing at the beginning of the session and several additional times during the session to watch the light bar when he is speaking to monitor his volume, but he is able to maintain an appropriate volume during the session.

Andy T. Andy is a 38 year old male who sustained a brain injury as a result of a car accident. He sustained a skull fracture and a large subarachnoid hemorrhage. He also had a tracheostomy.

Initially, Andy had very decreased volume, with the listener comfortable only when he/she was very close to Andy. Andy demonstrated severe oral apraxia and dysarthria. He had poor breath support, and could sustain a tone for less than 4 seconds. He was able to be cued to increase his volume but was very inconsistent. The inconsistency was due to his severe memory deficits causing him to forget the task of speaking louder.

Following a course of therapy to increase his breath support, increase his articulation clarity and his attention, he was introduced to the Visivox. He initially required maximal cuing to look at the light bar, but over the course of his therapy he was able to decrease the frequency of cuing to occasional, and to increase his volume to where he was able to be heard consistently at a distance of ten to fifteen feet. This patient was discharged and later returned to TLC, and it was interesting to note that Andy continued to be able to accurately monitor his volume without the use of the Visivox.

Conclusion

In attempting to locate a tool to provide objective measurement to a usually subject measure of loudness, I have found the Visivox to be a very useful aid. The Visivox, being a visual system, acts as a concrete cue for a client who may have memory deficits severe enough to forget the task of speaking louder when given only a verbal cue. It has been my experience that the simplicity of this augmentative aid made the use of it ideal for clients in our population. As a further benefit, it decreases the frustration to the therapist of having to argue with and restate to the client numerous times, a subjective feeling of loudness. I feel that this augmentative aid could be well utilized with other populations dealing with volume deficits: Deaf and Hard of Hearing; Asthma; laryngectomies; Parkinson's Disease, or any person who has difficulty attaining a loud enough volume to communicate emergency concerns and needs.