Simphiwe Khoza, Elizabeth M. Solomon, Tebogo Tsele-Tebakang
Email Address: [email protected]
Institution: University of Johannesburg
Faculty: Health sciences
Background: The following is a brief overview of a homoeopathic research project conducted by a 5th year Homoeopathy student in partial fulfilment of her Masters degree in Homoeopathy. The aim of this study was to determine, by means of case studies, the effect of homoeopathic simillimum treatment on professional vocalists (singers) suffering from voice disorders.
Methods: Ten professional male and female vocalists, age 20-40, were recruited, using purposive sampling, by placing advertisements at a music-recording studio in Gauteng, South Africa. The study was conducted over 12 weeks and took the form of case studies. Participants meeting the inclusion criteria completed a Singing Voice Handicap Index (SVHI) questionnaire to assess the severity of voice disorders and a detailed homoeopathic case was taken. The case was repertorised using Murphy’s repertory and a remedy was selected, based on the participant’s totality of symptoms. A single dose of the remedy in a 200cH was given. Five follow-up consultations took place at two-week intervals where the patient’s response to the remedy was assessed and managed in accordance with the principles of classical homoeopathic prescribing.
Data analysis: The data obtained from the initial and follow-up case forms was used to draw up comprehensive descriptive case studies. The scores from the SVHI were used to assess changes in voice quality of the participant over the course of treatment and the trends were graphically represented.
Results: All ten participants showed improvement in their general wellbeing which included mental, emotional and physical symptoms. The voice disorder symptoms showed a marked trend of improvement, as evidenced by a reduction of SVHI scores over the 12 week period.
Conclusion: The study is small and is not controlled, therefore definitive conclusions cannot be drawn, however the results suggest that classical homoeopathy is a promising alternative therapeutic modality for the treatment of functional voice disorders in professional vocalists.
Voice disorders are defined as any deviation in quality, pitch or other basic vocal attributes, which consistently interferes with vocal ability1 and affects the patient’s ability to use their voice efficiently. The term professional vocalist is defined as a person whose profession, vocation or source of income, relies heavily on the use of the voice in a musical context rather than ordinary speech2. Professional vocalists rely on the voice as their source of income and therefore maintaining the quality of their voice becomes imperative for them3. Professional singers are prone to vocal injuries because of the extraordinary demands placed on their voice during performances and rehearsals4. In addition, psychological factors such as stress and anxiety can also negatively influence voice quality and performance5.
Common symptoms of voice disorders
The following symptoms are commonly associated with voice disorders: hoarseness, aphonia (voice loss), breathy voice, reduced range of phonation, interruption to pitch or inappropriately high level of pitch, vocal fatigue, strain or struggle in use of voice, voice tremor and throat pain6. Associated symptoms may include chronic throat clearing, difficulty breathing, difficulty swallowing and acid reflux7.
Research design and methodology
This was a descriptive study, using case studies. Ten black male and female professional singers were recruited from a music-recording studio in Gauteng, South Africa. Participants completed a selection questionnaire to assess their suitability for the study.
In order to be included in the study participants had to:
- Sing for five or more hours a week as part of their profession.
- Perform voice warm-up exercises before singing.
- Experience voice changes during or after singing, which include one or more of the following symptoms: hoarseness, voice breaks, limitations in range of pitch, volume restrictions, voice fatigue, breathlessness while talking, chronic throat clearing, chronic coughing and difficulty breathing or swallowing.
- Experience voice changes that occur at least once in a two-week cycle or more frequently.
- Vocalists using medication for voice disorders.
- Smokers or ex-smokers who stopped less than a year ago.
- Use of chronic medication or serious medical conditions.
- Existing laryngeal pathology (determined by laryngoscopic examination, such as polyps and nodules). Voice disorders are divided into three main categories: organic, functional and those with organic vocal disorders were excluded from the study.
Participants were first referred to an E.N.T specialist for laryngoscopy, where the vocal cords were assessed for pathology. Participants meeting the inclusion criteria underwent an extensive homoeopathic case taking. Symptoms produced on mental, emotional, general and physical levels were then recorded on a standardised case taking form. A relevant physical examination was performed to assess the participant’s general health and participants then completed a modified SVHI questionnaire. The SVHI is a validated measurement8 consisting of 30 multiple-choice items examining self-perceived singing voice impairment and function and includes physical and emotional issues related to singing. The highest score on the questionnaire, indicating impairment is 144 and the least score is 0 indicating an absence of voice disorder.
Homoeopathic medication and treatment protocol
The most intense, characteristic and spontaneously given symptoms were selected for manual repertorisation, using the Murphy Repertory9. This process enabled the researcher to review remedies which could possibly fit the case and then check them against several Materia Medicas. From this process a simillimum remedy was selected. All cases were started with a single dose of the indicated remedy in the 200cH potency. Treatment was applied in accordance with the principles of classical homoeopathic prescribing, as indicated by Kent10 and De Schepper.11
Follow up consultations
Participants were asked to return for five follow up consultations which took place at two week intervals. At each consultation a follow-up case history and relevant physical examination was conducted. The case was evaluated in terms of the participant’s response to the remedy looking for whether there had been any improvement or changes occurring at the mental, general and physical level of the participants. New symptoms were evaluated in terms of Hering’s Law of Cure10, 11. Depending on the participant’s response to the remedy, the researcher considered either repeating the remedy, changing the potency or remedy, or waiting and allowing the remedy to continue its action. Participants completed the SVHI at the end of each consultation.
The data from the case forms and follow-up sheets were used to write in-depth descriptive case studies. The modified SVHI was used to monitor changes in the vocal symptoms and the results were represented in the form of a graph, illustrating changes in SVHI scores which corresponded to participants’ perceptions of their voice quality and function over the duration of the study. Conclusions regarding the efficacy of the homoeopathic treatment were based on the data obtained from the case studies and the scores obtained from the modified SVHI.
The following are three of the cases from the study which illustrate the process. They have been condensed to their salient points.
A black male age 37 presented with voice disorders occurring at least four times a week, for five years when he started to sing on a full time basis. The participant reported that he was having difficulty reaching certain pitches when singing. He had a choking sensation which was worse when he sang, which felt like something lodged in his throat, and felt the need to clear the throat. There was a lot of mucus in the throat and he had to spit it out from time to time, the mucus secretions were runny and clear or yellow. The participant mentioned that he was avoiding high-pitched songs because it aggravated the voice problem He was concerned about his health and felt a desperate need to find a cure for his hoarseness. He mentioned that music was his only career and without it, there was no source of income. He had lost confidence in his voice; he did not sing with comfort or ease anymore. Bp 150/100mmHg. He felt his elevated blood pressure was caused by stress and by his diet.
The participant mentioned that his energy levels fluctuated and he generally felt tired and listless and usually woke up feeling un-refreshed. He described his appetite as very good and felt hungry all the time. He got headaches when he had not eaten for a few hours. He was concerned about his weight yet could not cut back on his high calorie diet which was unbalanced as he ate a lot of fast foods. The participant complained of a burning pain in under his right arm.
He viewed himself as an outgoing person and he mentioned that he liked people doing things for him and tended to give orders. He had problems remembering the correct words to use when speaking. He expressed a need to try new things in life so that he had something to fall back on if his music career fails. The participant preferred solitude when going through a bad experience. He was about to get married and he said that this was a stressful time for him.
His SVHI score was 56/144.
1. Mind – anxiety – health
2. Mind – mistakes – speaking
3. Mind – concentration – difficult
4. Sleep – unrefreshing
5. General – pains – burning – externally
6. Food – appetite – ravenous
7. Headaches – general – fasting from
8. Throat – chocking
9. Larynx – mucus – in
10. Larynx – voice – hoarseness
Table A: Repertorisation of Case A
Prescription: A stat dose of Lycopodium 200cH. Four placebo powders one dose taken every second day
Motivation for selection of remedy
Lycopodium scored in all of the symptoms selected for repertorisation. People requiring this remedy feel weak, particularly, feeling of loss of internal strength, especially after every effort. There is great depression in men where even little things annoy12. Both the participant and the remedy picture display an aversion to undertaking new things, yet when undertaking something, he goes through with ease and comfort12. The Lycopodium patient can be dictatorial, headstrong but lacks self-confidence and has problem with anticipation12.
Both the participant and the Lycopodium picture exhibit:
- Concentration difficult during conversation;
- Love of power;
- Excessive hunger, the more he eats the more he craves;
- Hoarseness, weak voice and great accumulation of mucus in the throat;
- Sleep unrefreshing13
The participant reported fewer voice disorders, which dropped from four times a week to once in two weeks. The choking sensation in the throat experienced during singing was better. The sensation of something lodged in the throat was still there but to a lesser degree. He still cleared his throat and mucus secretions, clear to yellow, were still being expelled.
The participant mentioned that the pain under his left arm had disappeared; he associated the pain with thinking excessively. He reported that he tried not to think too much and had less fights with his fiancé because he had started helping around in the house.
He was still worried about his singing and had great fear about his career, he reported that he would like to have the powders long term in order to be able to sing with the same level of confidence that he had experienced in the past two weeks. Bp 150/95mmHg. SVHI score 19/144. This indicated considerable improvement in his voice disorders.
The researcher observed a remarkable improvement in the participant, noted in his fewer voice disorders, the amelioration in some of his physical symptoms and his subjective sense of getting better. The fact that the participant was showing initiative in helping his fiancé with house chores indicated great improvement as the Lycopodium picture indicates someone who is unwilling to undertake new things and enjoys it when things are done for them. His blood pressure was still high. The researcher decided to allow Lycopodium to continue its action.
Prescription: Five placebo powders were given, one dose taken every second day.
Second Follow up
The participant had been satisfied with the drop in frequency of voice disorders. The choking sensation was gone. The need to clear the throat was still there but to a lesser degree, mucus secretions had reduced.
He mentioned that he felt more energetic and he could not wait to get to the studio and sing. He was happy that he was not fighting with his fiancé anymore. He was happy that he woke up feeling more refreshed in the morning. He had started to drink more water. Bp 140/90mmHg. The participant did not answer the SVHI questionnaire due to his busy schedule; therefore, there was no score for this visit.
The participant seemed calmer and in control, he was more optimistic and there was a slight improvement in his systolic blood pressure.
Prescription: Five placebo powders were given, one dose taken every second day.
Third Follow up
The participant continued experiencing a decrease in voice disorder symptoms, which only occurred once in two weeks. The clearing of the throat was better and he had not experience choking in two weeks. The participant was more confident about his singing and he mentioned that he was rehearsing more and attempting to sing songs, which required higher pitch. He experienced one episode of under arm pain after becoming angry a week prior the consultation. Bp 135/90mmHg. SVHI score 9/144.
The participant mentioned that fights started with his fiancé. A week prior to the consultation he was very angry and there was outpouring of emotions but he had felt emotionally better the following day. The researcher interpreted this as a possible emotional elimination. Many of his physical symptoms had improved but the under arm pain had reoccurred. Blood pressure had improved but still required monitoring. The researcher decided to repeat the remedy.
Prescription: A stat dose of Lycopodium 200cH. Four placebo powders one dose taken every second day
Fourth Follow up
The participant had not experienced any voice disorders in the past two weeks and was delighted that he could sing for longer without experiencing any vocal fatigue. The emotional symptoms had improved. Bp 125/90 mmHg. SVHI score 6/144.
The participant was feeling better and he did not experience any emotional breakdown and there were no relapses in the past two weeks. His systolic blood pressure reading continued to improve. The researcher decided not to interfere with the action of the remedy.
Prescription: Five placebo powders were given, one dose taken every second day
The participant reported that his voice disorders were less and not as strong as before. His energy levels were better, his sleep was still good and he had no pain. He reported that he was more at ease, calmer with his singing and was working hard to accomplish his singing career. He had not experienced any emotional outbursts and he was teary eyed when he mentioned this. Bp 125/85 mmHg. SVHI score 7/144.
Overview of Case A
The remedy had elicited improvement on the mental, emotional and physical levels. The remedy was able to help maintain wellbeing for a month after its administration. The participant’s blood pressure was high in the first consultation and first follow up consultations but improved during the duration of the study. The participant was requested to monitor his blood pressure with his medical practitioner.
Initially the participant scored 56/144 on the singing voice handicap index questionnaire and at the last consultation totalled 7/144. This decline in the score indicates that the participant’s perception about his voice disorder had improved, although the second last score was 6 and the final one 7. He had originally experienced voice disorders at least four times a week and by the last consultation, he had not experienced any major voice disorders in a month.
Graph: A SVHI Questionnaire scores vs. consultations of case A
A 30-year-old black female presented with voice disorders which started, seven years ago. She had trouble in sustaining a pitch, and experienced hoarseness, relieved by drinking warm water, which had become worse in the last 2 months, causing severe stress and nervousness. She complained of a constant need to clear her throat, which always felt dry after singing.
She confessed being unhappy concerning her life, that she was not where she thought she would be by the age of 30. She described herself as weepy for no reason, whether in joy or sorrow. She described herself as very moody, quiet, friendly and trying hard to make things happen in her life. She expressed fears of being raped and losing her father. She was closed and reserved when discussing her childhood and said she had been raised by her paternal grandparents.
Her energy levels fluctuated but were often low before her lunch. She perspired frequently, mostly on her nose and face when stressed. She preferred cold weather but could not handle extreme temperatures. She complained of being unable to fall asleep; she would stay awake for hours before falling asleep.
She said she had an appetite for junk foods particularly biscuits and sweets. She described her menses as clotted and extremely irregular, as they could recur after a week when she was stressed. She complained of straining and difficulty passing stools. She also experienced frontal headaches with pain around the eyes and deep aching pains in knees better for rubbing.
Bp: 110/70mmHg. SVHI score 52/144.
1. Mind – crying – weeping – involuntary – joyful or sad
2. Environment – cold – temperature – ameliorates
3. Sleep – falling – late – night
4. Food – sweets – desires
5. Rectum – constipation – ineffectual
6. Female – menses – irregular
7. Knees – pain
8. Throat – dryness
9. Throat – clearing
10. Larynx – voice – irritating
Table B: Repertorisation for Case B
Prescription: A stat dose of Pulsatilla pratensis 200cH. Four placebo powders, one dose taken every second day
Motivation for remedy selection
Pulsatilla pratensis scored in all symptoms used for repertorisation. The emotional picture of Pulsatilla describes the patient as weepy, timid, highly irritable and miserable12. As in this case, patients are easily moved to tears, laughter, silent grief and sadness. One of the keynotes of this remedy is weeping while giving the symptoms, which is what the participant did during the consultation. The participant preferred cooler weather, which is a very important modality for Pulsatilla pratensis. Another modality of the Pulsatilla pratensis patient is the amelioration experienced by rubbing the effected parts like the knees12. The menses of Pulsatilla pratensis patient is changeable, intermittent and clotted12. Her hoarseness, which comes and goes accompanied with dryness in the throat, can all be found in the Materia Medica picture of the chosen simillimum13.
Some of the more general symptoms that were distinct in the case, reflecting the Pulsatilla pratensis picture includes:
- being wide awake in the evening yet sleepy during the day;
- craving food which disagrees, like sweets, butter and ice cream;
- participant did not drink much and Pulsatilla pratensis is thirstless
- great inclination to sweat particularly about the nose and face12.
The participant reported feeling more energetic and not as moody and irritable as she normally felt. She had her menses on the second week, which came with pains in her lower back. She experienced frontal headaches around the eyes during menses. She mentioned that the singing had improved, as the voice did not go hoarse as often as it had before the medication. She stated that she only experienced voice disorders twice in two weeks. Her quality of sleep had improved but she still felt un-refreshed and she fell asleep late at night. SVHI score 22/144
Many of the participant’s symptoms had improved but she there were many remaining symptoms. The researcher then decided to repeat the remedy.
Prescription: A stat dose of Pulsatilla pratensis 200cH was given. Four placebo powders one dose taken every second day.
The participant reported an immediate improvement in her hoarseness and in her ability to sustain pitch while singing. She experienced voice disorders once in two weeks. She mentioned that her stress levels were better and she was sleeping better. The headaches had gone since the last menstrual cycle she had. The knee pains were better and she was impressed with her mood and her quality of sleep. She mentioned that she had not been able to remember her dreams. Her improvement was more noticeable in the first week but symptoms were beginning to return. SVHI score 44/144.
The researcher was pleased with the participants’ response to the remedy. The remedy had helped to induce improvement on the mental, emotional and physical levels, thus affecting holistic relief. The participant felt that she experienced greater improvement in the first week. It was observed that she responded well but for too short a period. The SVHI score increased from 22/144 to 44/144, which could indicate an aggravation of her symptoms.
Prescription: A stat dose of Pulsatilla pratensis 200cH was given. Four placebo powders, one dose taken every second day.
The participant reported that her voice disorders were fewer than and not as strong as they were before the medication. Her sleep had improved and her energy levels were even better, she had not had a headache, she had her menstrual cycle after three and half weeks which was a great improvement for her and back pain and clots did not accompany her menses. She reported feeling better than the last three weeks. She was very happy about her mood improvement. The SVHI score 9/144.
The information given by the participant at the consultation led the researcher to believe that the remedy was still stimulating the vital force sufficiently to elicit emotional, mental and physical improvement.
Prescription: Five placebo powders, one dose taken every second day
The participant was very happy during the interview and she expressed how well her career was doing. She was happy about her sleep, her menstrual cycle and her mood. The SVHI score 11/144.
Prescription: Five placebo powders were given, one dose taken every second day
The participant reported that she had no major voice disorder in the past month. She was singing much better and she was friendlier towards her family members and co-workers. The SVHI score 4/144.
Overview of Case B
The participant responded favourably to the Pulsatilla pratensis. Three doses were given but the participant did better when the remedy was left to work. At the first follow up consultation the researcher probably repeated the remedy too quickly before the action of the previous remedy had exhausted its action. This may have resulted in an aggravation of local symptoms and a raised SVHI score. However the remedy elicited marked improvement on her mental and emotional levels and by the last consultation, the participant was very well and happy with the totality of her improvement.
Over the course of the study the SVHI score declined from 52/144 to 4/144. She originally experiencing voice disorders twice in two weeks and by the last consultation she had not experienced a notable voice disorder in a month.
Graph B: SVHI Questionnaire scores vs. consultation of Case B
A 24-year-old black female, presented with voice disorders that started with her singing career, 6 years ago. No abnormality was detected on laryngoscope and her BP was 130/90mmHg, it was observed that she was overweight. The participant presented with an intermittent voice disorders that came on after singing. She experienced a tickling sensation in the throat, which prompted her to clear the throat and this brought relief. She expressed difficulty in controlling her singing voice but she had not missed a performance as a result of it. There was pain in the larynx with poor voice production, the pain was localised along the larynx. Her initial score on the SVHI was 27/144. Associated symptoms included frequent coughing and throat clearing and great irritation in the larynx after having too many sweets.
Generals and Mental symptoms
The participant said that her energy levels were normal. She perspired frequently after little exertion, mostly on her face and covered parts like the backs of her knees and the legs. She preferred colder weather, as in summer her hair would break and she got a skin rash, which presented as small pimples, which clumped together and were very itchy. The only symptom that troubled her in winter was that her nose would become raw and burn, resulting in great discomfort. Her sleep was refreshing, she dreamed of being chased by dogs and falling from a building. She ate balanced meals, her appetite was very good and she ate throughout the day, she loved “sugary and salty foods”. Her menstrual cycle lasted for three days with slight discomfort in the lower abdomen at which time she had a stronger craving for sweets which made her feel sick.
When questioned about her emotional state, the participant described herself as a happy, confident, and extrovert person. She said she was a caring person who sometimes became emotional and weepy without cause. She mentioned that she felt frightened very easily, sometimes for the least little thing. She also mentioned that she would sometimes laugh in situations that were serious or when having to make a serious decision.