METHODS

published: 14 January 2020

doi: 10.3389/fpsyg.2019.02854

Using Beatboxing for Creative

Rehabilitation After Laryngectomy:
Experiences From a Public
Engagement Project
Thomas Moors 1 , Sanjeev Silva 1 , Donatella Maraschin 2 , David Young 3 , John M. Quinn 4 ,
John de Carpentier 5 , Johan Allouche 6 and Evangelos Himonides 7*
1
Shout at Cancer, London, United Kingdom, 2 School of Arts and Creative Industries, London South Bank University,
London, United Kingdom, 3 School of Science and Engineering, University of Dundee, Dundee, United Kingdom, 4 First
Faculty of Medicine, Institute of Hygiene and Epidemiology, Charles University, Prague, Czechia, 5 Royal Preston Hospital,
Preston, United Kingdom, 6 Hôpital Saint-Pierre, Brussels, Belgium, 7 UCL Institute of Education, University College London,
London, United Kingdom
Edited by:
Rosie Perkins,
Royal College of Music, Laryngectomy is the surgical removal of the larynx (voice box), usually performed in
United Kingdom patients with advanced stages of throat cancer. The psychosocial impact of losing the
Reviewed by: voice is significant, affecting a person’s professional and social life in a devastating
Kai Johannes Lorenz,
Bundeswehrkrankenhaus, Germany way, and a proportion of this patient group subsequently must overcome depression
Rob Van Son, (22–30%) and social isolation (40%). The profound changes to anatomical structures
The Netherlands Cancer Institute
(NKI), Netherlands
involved in voicing and articulation, as a result of surgery, radiotherapy or chemotherapy
*Correspondence:
(separately or in combination with one another), introduce challenges faced in speech
Evangelos Himonides rehabilitation and voice production that complicate social reintegration and quality of
[email protected] life. After laryngectomy, breathing, voicing, articulation and tongue movement are major
Specialty section:
components in restoring communication. Regular exercise of the chest, neck and
This article was submitted to oropharyngeal muscles, in particular, is important in controlling these components and
Performance Science,
keeping the involved structures supple. It is, however, a difficult task for a speech
a section of the journal
Frontiers in Psychology therapist to keep the patient engaged and motivated to practice these exercises. We
Received: 01 June 2019 have adopted a multidisciplinary approach to explore the use of basic beatboxing
Accepted: 02 December 2019 techniques to create a wide variety of exercises that are seen as fun and interactive and
Published: 14 January 2020
that maximize the use of the structures important in alaryngeal phonation. We herein
Citation:
Moors T, Silva S, Maraschin D,
report on our empirical work in developing patients’ skills, particularly relating to voiced
Young D, Quinn JM, de Carpentier J, and unvoiced consonants to improve intelligibility. In collaboration with a professional
Allouche J and Himonides E (2020)
beatboxing performer, we produced instructional online video materials to support
Using Beatboxing for Creative
Rehabilitation After Laryngectomy: patients working on their own and/or with support from speech therapists. Although the
Experiences From a Public present paper is focused predominantly on introducing the structure of the conducted
Engagement Project.
Front. Psychol. 10:2854.
workshops, the rationale for their design and the final public engagement performance,
doi: 10.3389/fpsyg.2019.02854 we also include feedback from participants to commence the critical discourse about

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Moors et al. Beatboxing After Laryngectomy

whether this type of activity could lead to systematic underlying research and robustly
assessed interventions in the future. Based on this exploratory work, we conclude that
the innovative approach that we employed was found to be engaging, useful, informative
and motivating. We conclude by offering our views regarding the limitations of our work
and the implications for future empirical research.
Keywords: head and neck cancer, throat cancer, voice rehabilitation, laryngectomy, beatboxing

INTRODUCTION research and organization of the disease management approach

(Gatta and Botta, 2017). In developing countries, this problem
Head and neck cancers (HNC) are a burgeoning public health
may be worse due to economic reasons limiting both access
burden worldwide, causing significant mortality and morbidity
to health-care provision that might allow early diagnosis and
despite clinical advances enabling early diagnosis and treatment
perhaps lead to non-surgical therapies, thus avoiding the need for
(Gupta et al., 2016, 2017). The estimated incidence rates of
laryngectomy (Staffieri et al., 2006; Stevens and Huys, 2017).
HNC are shifting toward predominance in the less and least
developed regions of the world, where health-care offerings may
be inadequately equipped to diagnose and appropriately treat Laryngectomy
HNC and, thus, health-care outcomes may be much worse as a Laryngectomy is usually performed in patients at later stages of
result (Gupta et al., 2016). Surgical intervention for HNC requires throat cancer. Cancer definitions from the new WHO update
significant expertise and can often have a serious impact on the divide tumors of the oral cavity and oropharynx into separate
quality of daily life; therefore, exploring novel support strategies chapters, classify SCCs of the oropharynx on the basis of
and activities as part of a holistic approach in rehabilitation might HPV status, abandon the practice of histologic grading for
ensure improved quality of life among those affected. oropharyngeal SCCs that are HPV-positive, recognize small
cell carcinoma of the oropharynx, and combine polymorphous
low-grade adenocarcinoma and cribriform adenocarcinoma of
BACKGROUND the tongue and minor salivary glands under the single term
‘polymorphous adenocarcinoma’ (Westra and Lewis, 2017).
Epidemiology In the presurgical situation, air is expelled from the lungs and
Head and neck cancers include cancer of the lips, oropharynx, passes from the trachea (the windpipe) through the larynx, where
hypopharynx, pharynx, major salivary glands, larynx and sinuses vibrations of the mucosa over the vocal folds (the glottis) create
according to the WHO classification of head and neck tumors a mucosal wave; this is known as the fundamental frequency.
and series on histological and genetic typing of human tumors In contrast, everything else above the laryngeal assembly that
(Gatta and Botta, 2017; Wright and Vered, 2017). HNC are participates in the shaping, amplification, dampening and
considered a rare cancer with reported annual incidence rates branding of the sound produced by the glottis is customarily
of less than six per 100,000 individuals and a prevalence called the vocal tract (including the soft tissue, cartilage, nasal
of less than five per 10,000 individuals in some populations cavity, tongue, teeth and lips; Welch et al., 2019).
(Gatta and Botta, 2017). When performing a laryngectomy, the surgeon preserves as
A large proportion (35%) of cases of HNC is laryngeal cancer much pharyngeal mucosa as possible to limit the defect created
(Cancer Research United Kingdom, 2019). A laryngectomy is and make the reconstruction of the neopharynx easier, avoid
only suggested in the advanced stages of throat cancer in an or minimize flap reconstruction, and facilitate voice recovery
effort to mitigate metastasis and mortality in this patient group. (Elmiyeh et al., 2010). The trachea is detached from the larynx
In developed countries, the number of laryngectomies performed and brought forward to be attached to the skin, creating a stoma
is low because of early presentation and ease of access to health (opening) in the front of the neck. It is important to note that,
care involving combinations of radiotherapy and chemotherapy. upon laryngectomy, the patients’ airway is not directly connected
In the United Kingdom (UK), for example, each year there with the mouth anymore: instead, they are breathing in and out
are approximately 500–600 laryngectomies performed, with 542 of the neck (Elmiyeh et al., 2010; Figure 1).
conducted in 2016–2017 (NHS, 2018). In the developing world, After removal of the larynx, a PE segment is reconstructed
however, many laryngeal cancers are diagnosed at more advanced with a resonating pharyngeal segment above it (Elmiyeh et al.,
stages and require total laryngectomy (Staffieri et al., 2006). 2010). The resonating segment will act as the main source of
Patients with HNC, in common with other ‘rare cancers’, vibration of the air expelled from the lungs and diverted into this
face difficulties in diagnosis, treatment planning, power of segment, resulting in sound production; it is therefore called the
neoglottis (Elmiyeh et al., 2010).
Abbreviations: E, oesophageal; EL, electrolaryngeal; HNC, head and neck The procedure is, in effect, a substantial amputation of the
cancers; HPV, human papillomavirus; IPA, International Phonetic Alphabet;
anatomy responsible for sound production. It affects both the
PE, pharyngoesophageal; SBN, Standard Beatbox Notation; SCC, squamous cell
carcinoma; TE, tracheoesophageal; UCL, University College London; WHO, afferent and efferent pathways for voice production and control.
World Health Organization. The whole speech production process and co-ordination, often

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Moors et al. Beatboxing After Laryngectomy

FIGURE 1 | Anatomical changes seen before and after laryngectomy (Drawing Claire Holmes).

When the stoma is occluded, the air has to escape and

is therefore pushed through the valve, causing vibration of
the neoglottis. Because of the small diameter of this valve,
it takes approximately 7.5 times more pressure to achieve
voicing when compared with normal laryngeal phonation
(Bohnenkamp et al., 2011).
To recommence speaking after laryngectomy, a new co-
ordination strategy is required to prepare and control breathing
and for manually occluding the stoma at precisely the right
moment so that sufficient pressure can build up to open the valve
and divert air through the valve into the neopharynx, where it
forms a vibrating column of air as it passes upwards through
the neo-glottis. This column of vibrating air can be articulated
into sounds and speech similar to the way described earlier
(Bohnenkamp et al., 2011).
Overall, this approach produces a more natural sound,
requires greater power from the lungs, facilitates more volume
control (van As et al., 1998; Jongmans et al., 2006; Kaye
et al., 2017), makes it easier to differentiate between voiced
and unvoiced consonants (Jongmans et al., 2006), is expensive
FIGURE 2 | Airflow and voicing in TE speech (Drawing, Claire Holmes). and necessitates that the valve be replaced every 3–6 months
(Staffieri et al., 2006), and offers patients a higher degree of voice
satisfaction (Kaye et al., 2017).
including hand movements, need to be relearned or adjusted
depending on which type of voice restoration has been employed.
Electrolarynx (EL) Voice
With this solution, there is no valve connecting the trachea with
There are four different ways to restore speech, with
the neopharynx; instead, an artificial vibrating device is held
TE voice among them nowadays considered to be the
against the user’s throat or cheek. When switched on, controlled
gold standard (Jongmans et al., 2006; Elmiyeh et al., 2010;
by its user’s thumb, the sound vibration is transmitted to the oral
Bohnenkamp et al., 2011).
cavity, where it is articulated into speech (Elmiyeh et al., 2010;
Kaye et al., 2017).
TE Voice This approach produces a monotonous, electronic sound;
In this approach, a surgical puncture allows the placement of a facilitates the speaking of unlimited words; is easy to learn;
replaceable unidirectional valve that diverts air from the trachea requires an expensive first purchase but subsequent maintenance
into the esophagus (Figure 2). is cheap; and makes it difficult to differentiate voiced from

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Moors et al. Beatboxing After Laryngectomy

unvoiced consonants, depending on hand coordination This complex process is thought to become
(Kaye et al., 2017). automatic in speech once development is complete
(Smith and Zelaznik, 2004). It is obvious that a laryngectomy or
Esophageal (E) Voice the removal of the anatomical part responsible for initiating the
E speakers don’t have a valve connecting the trachea with vibration that results in voicing affects this vocal motor system.
the esophagus. Instead, air is drawn into the upper esophagus Cohen et al. (1991) showed that lesions, like amputations,
and then released into the mouth, producing vibrations cause a neuroplastic reorganization of motor outputs in the
in the pharyngeal and PE wall that generates a sound brain targeting the muscles proximal to the injury, allowing for
(Elmiyeh et al., 2010). a rapid reallocation of the available neural networking. We can
Here, the sounds, volume and number of words are limited; expect a similar response in the affected vocal motor system after
the sound produced is monotonous; the technique is harder laryngectomy because of the suggested specific cortical area for
to learn; there is no extra cost or need for regular valve the larynx and articulators (Kleber et al., 2010), even though the
replacements; and it is difficult to differentiate voiced from laryngeal and orofacial muscle fibers are distinct from peripheral
unvoiced consonants (Kaye et al., 2017). muscles (Kent, 2004).
It is suggested that regular practice with great attention
Mouthing or Lip Speech to auditory and kinesthetic feedback (e.g., from laryngeal
When all other options fail or are not available, patients can mechanoreceptors) for vocal control helps voice professionals
over-articulate and make limited use of sounds solely using optimize the co-ordination of the vocal motor system, including
their mouths. With this approach, no sound is produced, there the articulators and larynx (Sundberg, 1987; Mürbe et al., 2004).
is difficulty differentiating voiced and unvoiced consonants, Kleber et al. (2010) also suggest that vocal training increases
intelligibility is limited and there is no need for medical devices. the involvement of implicit memories of movement control,
One of the difficulties experienced in speech after while Mürbe et al. (2004) postulated that the auditory feedback
laryngectomy, in addition to the issues of volume control is most important in the early stages of vocal training, with
and pitch range, is the differentiation between voiced and a fundamental role in pitch control, and that the kinesthetic
unvoiced consonants (Jongmans et al., 2006). The variation feedback circuit seems to be particularly improved (e.g., in
between these consonants simply depends on whether or not classical singing) after years of training (Mürbe et al., 2004).
the voice is used to support the articulation. TE phonation Therefore we suggest that, during the (initial) relearning
demands a controlled expiration through the valve that phases for controlling the new vocal instrument in order to speak,
causes the PE segment to vibrate. For E speech, this is even patients who underwent laryngectomy need to be supported
more difficult, as the phonation comes from swallowed whilst exploring their voices and practicing phonation effectively
air, while, in the context of EL voice, it depends on the and systematically. Any effective means to foster, maintain,
digital control of the device. Therefore for both E and EL and/or increase the motivation for patients to practice and try to
phonation, success comes down to the combination of lip improve would be welcome.
speech and their voicing techniques. Lip speech is hardly
practiced in the West, but we assume that it is more frequent Beatboxing
in developing countries where patients face difficulty in At its base nature, beatboxing is the art of vocal percussion; more
accessing facilities and medical devices (Staffieri et al., 2006). recently, it has been linked to what is now described as ‘hip-hop’
Nevertheless, evidence suggests that it will add to the clarity of culture and is popular amongst younger audiences and artists
both E and EL voice. (Stowell and Plumbley, 2008). Beatboxing employs multiple
The psychosocial impact of losing the voice is significant, beat modalities, including vocal instruments, to produce both
affecting a person’s professional and social life in a devastating rhythmic and melodic sounds. These sounds are often perceived
way (Dooks et al., 2012; Keszte et al., 2013). A high percentage as overlapping (occurring in synchrony) in time. The majority
of this group suffers from social withdrawal (40%; Danker of beatboxing sounds imitate percussion instruments like drums
et al., 2010) and depression (22–30%; Bussian et al., 2010; and cymbals yet are also seen as similar to speech sounds
Danker et al., 2010; Dooks et al., 2012; Keszte et al., 2013; and can be described using symbols from the International
Perry et al., 2015). Phonetic Alphabet (IPA; Stowell and Plumbley, 2008; Stowell
and Plumbley, 2010; Proctor et al., 2013)1 or with the use of
Speech Production characters from a standard English computer keyboard as in the
Normal speech (and singing) requires the involvement of more SBN (Splinter and TyTe, 2002).
than 100 muscles. It is remarkable that this process takes place Despite this similarity with sounds used in speech, beatboxers
entirely within the body without visual control over movement explore their instruments continually and have been ‘inventing’
(Kleber et al., 2010). and introducing novel sounds that are non-native to them
The interaction between the activity of the vocal folds, (Proctor et al., 2013) or even extralinguistic (Proctor et al., 2013;
larynx, respiration and articulators is fine-tuned (Dejonckere and de Torcy et al., 2014).
Lebacq, 1981) and performed at a fast rate, necessitating the
presence of a control system that mainly depends on an intrinsic
reflex system (Abo-El-Enein and Wyke, 1966). 1
http://www.mcld.co.uk/beatboxalphabet/

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Moors et al. Beatboxing After Laryngectomy

Beatboxing is inexpensive, as no purchase of instruments informed consent was obtained from all participants and, in the
or technical equipment is required to start learning the basics. case of the young performers, written informed consent was
Beatboxing is also presented as a pluralistic and democratic obtained from their legal guardians.
artform (Himonides et al., 2018) where ‘every sound is valid.’ We
felt that it would be worth investigating whether this inexpensive Workshops
and easily accessible activity could be of use in speech pathology We organized five workshops, each lasting 2 h, that were held
and, particularly, in rehabilitation after laryngectomy. weekly. The defined goals of the workshops were:

Why Beatboxing and Laryngectomy? (1) To engage a vulnerable group of individuals in collaborative
Proctor et al. (2013) showed that beatboxers, like other voice music-making using novel techniques (i.e., beatboxing),
professionals, display an increase in the sensorimotor areas (2) To engage a wider group of local youth in East London in
specific for voicing but that this fine-tuned control is ‘exploited’ artistic expression and collaboration with cancer patients,
to obtain a musical effect. and
Due to the surgical changes in anatomy after laryngectomy, (3) To engage a wider public audience in an open showcase
other interesting and potentially beneficial aspects of beatboxing of masterclass outcomes/concert to explore the use of
include the skill of detaching laryngeal from pharyngeal activity beatboxing techniques in laryngectomy.
(de Torcy et al., 2014) using the hypopharynx as an individual
resonator (Kitamura et al., 2005) and the ability to create plosive During the workshops, we explored whether beatboxing
sounds with a closed glottis independent of the airflow used techniques are applicable in speech rehabilitation after
for breathing support (de Torcy et al., 2014). An analysis of laryngectomy. Patients, clinicians and speech-language
imaging (Proctor et al., 2013) showed a diversity existed in pathologists were invited to participate with the beatboxer
tongue movement, supporting the possible benefits of beatboxing in developing vocal and breathing skills. We focused on
techniques in promoting suppleness and linking articulation to unvoiced and voiced consonants in lip speech, EL and TE voice.
breathing control and voicing. We followed the basic beatboxing sounds described in Tables 1,
Overall, all of these factors support the usefulness of 2. We approached the exploration of the consonants, used in the
beatboxing in TE, EL, E and lip speech. The rhythmic, playful and English language, as beatboxing sounds (Table 3). Participants
explorative approach makes it a useful tool to motivate people to practiced the sounds separately at first and then in different
practice co-ordination in voicing and improve intelligibility. rhythms and combinations to refine and improve the hand,
Here, we used beatboxing to explore the alaryngeal voice, breathing and voicing co-ordination.
breathing control and vocal pitch, paying particular attention to In the last two sessions, we included local youth, specifically
unvoiced and voiced sounds. An additional reason for exploring four boys and two girls between six and 13 years old, who were
the use of beatboxing was because it is perceived to be a fun introduced to basic beatboxing. They practiced together with
activity, is simple and cheap to conduct, and can be readily the patients after an introduction and explanatory talks about
adapted for online participation, thus improving accessibility. laryngectomy. We prepared the songs of the program for the
concert 3 weeks later. They were encouraged to interact with the
patients and to ask questions.
MATERIALS AND METHODS At first, we introduced three basic beatboxing sounds (see
Figure 3): the classic kick drum ({b}, [p’ ]), the basic or closed
°

This project involved Shout at Cancer (a non-profit organization hi-hat ({t}, [ts t ]) and the rimshot ({k} [k']). We started to work
specializing in post-laryngectomy voice), Marv Radio (a on each sound separately to focus on pronunciation, controlling
beatboxer), UCL music education researchers/facilitators, a volume and tempo. To practice the control of volume, we
group of cancer survivors with laryngectomy coming from across pronounced the same sound at different levels of loudness, from
the United Kingdom, local East London youth, and an audience soft to loud and then at random (e.g., for the kick drum: b,b,b;
(for the final public performance) that involved families and B,B,B; B,B,B; or bBb).
guests from across London and the United Kingdom. We worked on the co-ordination of breathing and voicing
There were nine laryngectomy patients, including six males by repeating the same sound in different tempos, increasing the
and three females, with a mean age of 65 years. Seven used speed of pronouncing the same sound and progressing from
TE voice, one voiced with an EL, and one relied on lip slowly to as fast as possible. During the exercise, it was important
speech or mouthing. to pronounce the sound properly.
Inclusion criteria were total laryngectomy using TE, E, EL or For example: b, b, b b,b,b b,b,b
lip speech. There were no exclusion criteria. We combined both exercises to work on a better control
The present study did not require research ethics approval of speed and volume at the same time For example: b, B,
as confirmed by the joint Medical Research Council (MRC) and B, bbb, B, B, bbb.
United Kingdom National Health Service (NHS) Health Research The next step, to make it more playful and to help participants
Authority online ethics assessment tool2 . Nevertheless, written understand how easily these exercises can be built into their daily
routine, we exercised with rhythms from familiar dance styles
2
http://www.hra-decisiontools.org.uk/ethics/index.html or famous songs (e.g., waltz, samba, tango, salsa, ‘We Will Rock

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Moors et al. Beatboxing After Laryngectomy

TABLE 1 | Musical classification and the phonetic description of the basic beatboxing sounds used during the workshops based on the description used in prior
research (Proctor et al., 2013; IPA, 2015), the SBN (Splinter and TyTe, 2002) and the phonological description of consonants (O’Grady et al., 2017).

Name/picture Description SBN IPA

Rimshot Imitation of the sound of hitting the drumstick against the rim of the drum or like two drumsticks hit {k} [k']
against each other.
The sound is achieved by pronouncing the k, a voiceless velar stop or plosive.

Classic kick Soft and low pitch sound, an imitation of the big drum on the drum set. {b} [p’ ° ]
The sound is achieved by pronouncing the letter b, a voiced bilabial stop or plosive.

Basic or Closed A high-pitched and prolonged sound imitation of the hi-hat, as it is resonating more in the open {t} [ts t ]
hi-hat position.
The sound is achieved by adding a prolonged s to the t.
Made by starting with a voiceless alveolar stop or plosive (t) and adding a prolonged voiceless
alveolar fricative (s).

Dry Kick A low pitched sound imitation of the big drum on the drum set, like the earlier described classic kick. {d} [d ° ]
The sound this time, however, is achieved by pronouncing a d, a voiced alveolar stop or plosive.

Open hi- hat A high pitch and prolonged sound imitation of the hi-hat, as it is resonating more in the open {ts} [ ts ]
position.
The sound is achieved by adding a prolonged s to the t.
Starting with a voiceless alveolar stop or plosive (t) and adding a prolonged
Whenvoiceless
the drumalveolar
is hit, the snare starts vibrating
fricative (s).
over the drum skin below.
Classic snare The snare drum owes its typical sound to the metal strings (snare) mounted on its underside. {pf} [pf’ ú° ]
The sound is achieved by pronouncing a ​p​,
When the drum is hit, the snare starts vibrating over the drum skin below.
The sound is achieved by pronouncing a p, a voiceless bilabial stop, oraplosive,
voicelessand
bilabial stop,
adding a or plosive, and adding a
prolonged f, a voiceless labiodental fricative, to it.
prolonged ​f​, a voiceless labiodental fricative, to it.

Cymbals CymbalsThe sound

The cymbal is loud, high-pitched, and has a lot of resonation. Theiscymbal
achieved is loud, high-pitched, and has a{T}
by starting lot of {T} [tɕːʷ]
with a forced t, voiceless alveolar stop or plosive and adding a well-supported ‘sh’The
resonation. sound,
sounda is achieved by starting with
voiceless alveolo-palatal fricative, to it.
a forced ​t​, voiceless alveolar stop or plosive and
adding a well-supported ​‘sh’​ sound, a voiceless
alveolo-palatal fricative, to it.

You’ by Queen). The integration of these exercises into music Once the participants understood basic beatboxing—that is,
facilitated practicing individually. the idea of repeating sounds in different levels of volume and
The workshops were structured in a repetitive way with a rhythms—we started to introduce more sounds and helped them
variety of actions with an increasing level of difficulty. interact more with the beatboxer and each other.
The next step focused on developing the participants’ control The beatboxer demonstrated challenging combinations that
of the volume of a sequence of different sounds, allowing them they had to repeat all together, in pairs or individually.
to link breathing and voicing control to a limited set of different Several times during the workshops, we conducted
positioning of the articulators and paying careful attention to battles where the beatboxer challenged the participants or
Figure 4. Woodblocks are displayed from left to right in decreasing pitch or increasing size. The
its pronunciation. the participants had to ‘provoke’ each other with difficult
highlighted size of the woodblock changes each time the picture is displayed, inviting the participant to
For example: b,t,k B,T,K B,T,K or bTk. combinations for the other to repeat.
Again, we continued by increasing the speed of explore the different For(apical alveolar) clicking sounds and different pitches achieved by adjusting the tongue
example: b, t, t, K, T b, t,t,t,t k, K, k, B.
movement and mouth opening.
pronounced sounds. Near the end of each session, we spent time trying to
For example: b, t, k b,t,k b,t,k, come up with new sounds. Initially, this idea appeared
We ended up going really fast and practiced using rhythms difficult to understand and was met with some hesitation.
from familiar dance styles or famous songs. The changes in tempo To support the participants with the challenge, we invited
and in rhythm add a gradient of fun to the exercise; they also them to imitate different sounds that we are likely to be
make it a cognitive exercise as it demands more concentration. familiar with, such as a dog barking, a helicopter, a car

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TABLE 2 | Additional sounds (IPA, 2015). Furthermore, it showed to the patients that sound can be created
without voicing.
Name Sound description IPA

Wood block A woodblock is a percussion instrument [!] Lip Speech or Mouthing

that has a warm and hollow sound; it
To explain how beatboxing could possibly make lip speech or
comes in different sizes, each with a
different pitch. mouthing more clear, we focused on tongue clicks at first. The
The sound is achieved by a tongue click, beatboxer demonstrated how changing the shape and opening of
apical (post)alveolar click and changes in the mouth influences the pitch of the sound. We then practiced
the shape of the mouth cavity to change pitch control of the clicking sounds in the group and individually.
pitch.
The next step was to shape the vocal tract to obtain the vowels
Whip or Slapstick The whip, slapstick, or clapper creates a
A, E, I, O, and U in combination with the clicking sounds. We
cracking noise.
repeated the vowels obtained with clicking sounds, changing the
The sound is achieved by a tongue click, a
laminal postalveolar click and a volume, rhythm and pitch.
simultaneous mouth opening. After the group felt more confident in being creative enough
to give shape to vowels without using voice, we explained
what the difference is between voiced and unvoiced consonants.
Table 3 shows the protocol/set of sounds that we tried to follow
passing by, a car braking or honking, a phone ringing systematically. We focused on tackling the production of the
or a bee buzzing. paired sounds t and d, p and b, f and v, s and z, and k and g
When the group felt more confident, we let the participants because these were close to the basic beatboxing sounds we had
and the children challenge others in the group with different covered already.
sounds they had invented. This was a playful way to improve the For each pair, we repeated each one four times (e.g., p
cohesion of the group and help each other explore sounds. p p p b b b b, p p p p b b b b). To make it slightly
By the end of the series of workshops, we had built up a harder, we included variations in tempo and volume. Then,
repertoire of varying beats and vocal tricks and integrated these in we encouraged the participants to pronounce the voiced and
the selection of songs for our performance. In one of the songs, we
nare starts vibrating non-voiced paired consonants alternatively (e.g., p b p b p
imitated the loud world we live in, building up the chaos gradually b p b), again continuing with changing the required volume
with the whole group together. We then stopped abruptly and and tempo. We finished these series of exercises by combining
pronouncing a ​p​,made the crowd reflect: imagine struggling with your voice, living all the sounds randomly where the group had to imitate
in our
r plosive, and adding a loud and fast world. the voice coach or each other when we divided them up in
The main beatboxing sounds we included in the further
biodental fricative, to it.
pairs to practice.
workshops and the music we prepared for the concert were At this point, the participants were paying more attention to
itched, and has acymbals
lot of {({T},
T } [tɕːʷ]), basic or closed hi-hat ({t}, [ts t ]), open hi- the co-ordination in using or not using voice in articulation.
chieved by starting ({ts}, [ ts ]), rimshot ({k}, [k']), classic snare ({pf}, [pf’ ú° ]), classic
hatwith We then explored in a similar way as above the more subtle
paired consonants θ and ð, and Z, and Ù and Ã. The nasal
R
ar stop or plosive and drum ({b}, [p’ ]) and dry kick drum ({d}, [d ] ).
kick ° °

h’​ sound, a voicelessTongue-click sounds were a way to do warm-up exercises for sounds m, n and η are difficult to pronounce in mouthing or
the jaw and the tongue (e.g., whip or slapstick or wood block lip speech and we did not find beatboxing sounds to make these
it.
[!]) (Figures 4, 5). These also represent an easier way to practice consonants easier to differentiate.
rhythms within a group, as they do not require co-ordination We approached the consonant L in a similar way as the tongue
among breathing, hand movement, voicing and articulation. clicks, changing the pitch of the sound by adjusting the mouth

TABLE 3 | Voiced and unvoiced consonants described anatomically and according to the manners of articulation (O’Grady et al., 2017).

Manner of articulation Unvoiced/ voiced Anatomical placement of the articulated consonant

Bilabial Labiodental Interdental Alveolar Palatal Velar

ecreasing pitch or increasing size. The
Obstruent
icture is displayed, Stopto
inviting the participant Unvoiced p t k
erent pitches achieved by adjusting the tongue Voiced b d g
θ
R
Fricative Unvoiced f s
Voiced v ð z Z
Affricate Unvoiced Ù
Voiced Ã
sonorant Nasal Voiced m n η
Liquids Voiced I ô
Glides Voiced w j

Note that the glottal sounds have been left out because of the level of difficulty for the laryngectomy patient.

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Moors et al. Beatboxing After Laryngectomy

opening. The exercise here was to make the sound of pouring

water from a bottle in a glass, in a slow or fast way.

TE Speech
The exercises for TE speech focused on linking breathing to
hand co-ordination, phonation and articulation and establishing
a clear distinction between the voiced and unvoiced consonants.
We aimed to begin each workshop with breathing exercises FIGURE 3 | From left to right: Rimshot, Hi-hat, snare drum, kick drum, and
as a warm-up, paying a lot of attention to control the expiration cymbal. When the picture is displayed, the patient is invited to imitate his/her
through the speech valve and out of the mouth without causing interpretation of the sound made by the instrument. Thanks to a visual input
only, the patient is freer to explore his or her expression without having been
the neoglottis to vibrate or phonate. influenced by someone else’s performance.
We encouraged the participants to prolong the unvoiced
consonants f and s for 5 s, building up to 10 s. The next step was
to steadily grow louder or the other way around. Following this,
they were helped to pronounce an f or s sound five times, each
RESULTS
lasting approximately for a second, followed by a 1-s pause. Once
they were able to control the f and s sounds, they were asked to
Pictures
flow over from a prolonged f into a v sound or an s into a z. We translated the basic sounds of beatboxing (Tables 1, 2),
Then, we started to practice series of five times repeating f and into pictures and invited artist Claire Holmes to create bespoke
v alternatively (e.g., f v f v f v f v f v or s z s z s z s z s z). graphics for our learning materials (Figure 3).
These exercises seemed to help the participants focus on
voiced and unvoiced sounds and, from then on, we systematically Video
followed the consonants presented in Table 3. We tackled the We created a series of video exercises in which the beatboxer first
following paired sounds—t and d, p and b, f and v, s and z, and k demonstrates the basic beatboxing sounds one by one, followed
and g—because they are close to the basic beatboxing sounds we by a variety of different combinations of these basic beatboxing
had covered already. sounds in different levels of difficulty and tempo. Participants are
Next, we made them pronounce the voiced and unvoiced invited to repeat each exercise.
paired consonants alternatively (e.g., p b p b p b p b), again
continuing with changing the required volume and tempo. We TE Consonants
finished these series of exercises by combining all of the sounds Thanks to breathing control, it is possible to make a difference
randomly in a scenario where the group had to imitate the voice between voiced and unvoiced consonants in the TE voice.
coach or each other when we divided them into pairs to practice. We had the patients practice different rhythms and sound
We then explored in a similar way as above the more subtle combinations in which there is a change from voiced to unvoiced
paired consonants θ and ð, Z and Ù, and Ù and Ã. Unlike in lip consonants (Table 2).
speech or mouthing, the nasal sounds m, n and η are easy to
pronounce in TE speech. In fact, we used these sounds to work Lip Speech Consonants
on resonance and made the group imitate car or bike engines that We explored how to make the differences between voiced and
were accelerating, slowing down, or hitting their brakes. unvoiced consonants used in English more clear by adding
The advantage of TE speech, unlike the other voice restoration sounds supporting the voiced consonants (Table 3; also, a
possibilities, is the airflow that supports voicing. An interesting supporting video on the Shout at Cancer website3 is available).
exercise to control airflow with or without voicing is rolling the r
sound. To make it engaging, we imitated growling dogs. Electrolarynx
We provided an EL to our beatboxer, who explored and
The Concert demonstrated the beatboxing possibilities with the device.
These workshops culminated in a public performance, the world With our laryngectomy participants, we worked on the
premiere of Beatboxing Without a Voice, at the Olympic Village, combination of lip speech techniques to obtain unvoiced
Stratford, East London on 8 April 2017. This concert was an consonants without the use of the electrolarynx and a smooth co-
interactive session involving local people and families across ordination of the use of the device to obtain vowels and voiced
London, the patients, an opera singer and the beatboxer. The consonants. These demand a high amount of attention, initially
research team also offered brief explanatory talks presenting is frustrating to use, and is hard to maintain4 .
the layered impact of throat cancer and laryngectomy. There
were over 130 people in the audience (this included confirmed Workshop With Local Youth
bookings as well as Olympic Village visitors who tagged along The workshop allowed the patients to be more comfortable and
without prior registration). to explore sounds without judgement from outside the group.
Those at the public performance were invited to provide
feedback not only about their experience but also about the 3
http://www.shoutatcancer.org/beatboxing
knowledge that they gained/acquired regarding throat cancer. 4
http://bit.ly/2Sl5Ye7

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Moors et al. Beatboxing After Laryngectomy

It also helped us in the preparation of the patients and to get TABLE 4 | Laryngectomees’ short evaluation of their beatboxing experiences.
the youth familiarized with the aftereffects of laryngectomy. We
Participant Q1 Q2 Q3 Q4 Q5 Q6 average
included the young participants in talks about laryngectomy
during the performance. p1 7 7 7 7 7 7 7.0
p2 7 7 7 7 7 7 7.0
Working With Voice Professionals p3 7 7 7 7 7 7 7.0
For some of the voice professionals, it was the first time they p4 6 4 3 5 5 5 4.7
had been involved in a beatboxing program. Although focused p5 7 6 7 6 7 7 6.7
on the alaryngeal voice, it was interesting for the health-care p6 7 4 6 4 5 4 5.0
professional to explore the voice in a different way, determine p7 3 3 3 3 3 3 3.0
overlapping skills and be able to explain sounds in a different way. p8 7 3 7 5 – 7 5.8
The team reported to have benefited from the techniques learned Average 6.4 5.1 5.9 5.5 5.9 5.9 5.8
in the project and will be able to implement these in their own
clinical or client-based activities.
be a very meaningful exploratory process where not only key
Beatboxer challenges but also useful methods were identified.
The beatboxing artist involved in the project faced the incredibly All participant laryngectomees were invited to offer feedback
challenging task of having to learn to take other people’s about their beatboxing experience using SMS messaging (for
physical constraints and limitations into account and also being convenience) and/or email. Participants were asked to rate the
required to form an understanding about the pathology and extent to which they agreed or disagreed with the following six
social impact on patients after laryngectomy. He worked hard statements:
in trying to explore a voice with so many restrictions. This was (1) I enjoyed participating in the project,
an incredibly challenging process for a freestyle artist, and the (2) I benefited psychologically from participating in the project,
research team witnessed a professional with incredible talent. (3) My voice production ability has benefited from
The interaction with both patients and health-care professionals participating in the project,
was challenging, and the learning curve was steep and required (4) I felt more confident about myself after participating in the
continual adjustment and critical thinking. project,
(5) I would recommend beatboxing to other laryngectomees,
Final Performance and Feedback (6) I would participate in a beatboxing project again in the
The project exceeded the aims set out in the initial proposal. future.
Beatboxing after laryngectomy had an impact at several levels,
including on both the individuals and the partners involved and All responses appeared to be positive but not overwhelmingly
potentially on future research. so (Table 4). Nevertheless, as hinted above, only one
However, this type of activity was not viewed enthusiastically laryngectomee appeared to have an overall negative view
by all laryngectomees. One participant was particularly negative about their participation in the project; all other respondents
about beatboxing as an artform and reported that they did not offered ratings with a strong sense of positivity (average
enjoy the workshops, the music or working with the beatboxing score = 6.2 points, standard deviation = 1.01 points).
expert. Somewhat paradoxically, though, even that particular Out of the 130+ final concert participants, 58 individuals
participant reported that the umbrella of activities leading to the offered feedback on an online survey instrument, a link to which
final public engagement concert seemed to offer some benefits for was made available post-concert using registered participants’
developing breathing control as well as for exercising the different email addresses. Participants were allowed to offer ratings
structures for alaryngeal phonation. This was particularly due to about the extent to which they agreed or disagreed with three
beatboxing’s strong reliance on rhythmic precision and adhering statements. They were also offered the chance to provide free
to strict rhythmical patterns. text feedback in a dedicated textbox. Ratings were performed on
Although the present work was primarily centred on public a seven-point Likert-type scale, and the available scores ranged
engagement and was not intended to form a clinical research from one point (completely disagree) to seven points (completely
study or intervention study, the team nonetheless decided to agree), with four points denoting neutrality (neither agree nor
record some feedback from the participants and the participating disagree). The three statements that participants were invited
audience. This was seen as essential to gauge the potential or to rate were: ‘I enjoyed participating in this event,’ ‘I feel that
value for similar work to play a key role in a future, systematically my understanding about laryngectomy is greater because of this
researched project. event’ and ‘I would like to attend a similar event in the future.’
Throughout the span of this work, the laryngectomees, Responses were overwhelmingly positive, therefore negating
the core team, the artist, and the collaborating speech and the need for the identification of commonality or diversity in
language pathologists/therapists worked in synergy to tweak the response between different age or sex groups. Table 5 summarizes
beatboxing exercises/tasks to a level where there was a good participants’ responses to the three statements.
balance achieved between task-appropriateness for the patients In addition to the rating of the three statements, 18
and artistic value for a beatboxing performance. This proved to participants offered further comments in the available textbox.

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Moors et al. Beatboxing After Laryngectomy

TABLE 5 | Final performance participants’ online evaluation.

Question Number of responses per scale item Mean rating Total

1 2 3 4 5 6 7

I enjoyed participating 0 0 0 0 0 8 50 6.86 58

in this event
I feel that my 0 0 0 1 7 9 41 6.55 58
understanding about
laryngectomy is greater
because of this event
I would like to attend a 0 0 0 2 3 10 43 6.62 58
similar event in the
future

In line with the inordinate positivity shown in the ratings,

participants offered optimistic commentaries. Some examples are
as follows:
• ‘It was a great experience. I felt at ease and look forward to
many more similar events in the future.’ FIGURE 4 | Woodblocks are displayed from left to right in decreasing pitch or
increasing size. The highlighted size of the woodblock changes each time the
• ‘A thrill to have been there, so inspiring, keep up the
picture is displayed, inviting the participant to explore different (apical alveolar)
amazing work.’ clicking sounds and different pitches achieved by adjusting the tongue
• ‘Amazing effort! Sentences like "I cannot" look ridiculous movement and mouth opening.
to be said by anyone about anything after this event!
Congratulations!’
• ‘This event was truly inspirational. To hear the stories of the not alone, and that they can achieve anything that they put
larynx group, accompanied by the beautiful words spoken their mind to. There is life after laryngectomy! And events
by the children and then the great music really touched like this will educate the public on these forgotten patients
my heart. I think the work of all those involved should and their condition.’
be applauded and supported. I hope in the future similar • ‘Fantastic!! Great community feel to the event, very
events can happen to raise awareness and get the needs of entertaining and thought-provoking.’
this condition more in the public eye.’ • ‘It was a wonderful and inspiring afternoon. What a
• ‘Really interesting to see the work done and the progress fabulous project. I thought everyone involved especially the
made by the alaryngeal individuals, and learn more about participants were amazing. It was also educational to hear
the challenges they face and what can be done.’ details about the effects of not having a larynx. Profoundly
• ‘The speeches delivered by some of the participants were moving experience.’
moving and thought-provoking. Understanding that the
operation not only removes the voice box but also make One comment in particular seemed to capture the ethos
the act of breathing so much harder gave me a new sense of this work and the importance of public engagement,
of respect and appreciation for what these people are stating ‘This event was an amazing celebration of why we
going through. The courage and physical stamina they have need this type of public engagement. What a waste of time
shown in the face of their situation is a massive inspiration.’ would it have been for all these wonderful people to practice
• ‘This was absolutely brilliant! I still feel blessed. Thank you beatboxing inside a hospital, in front of researchers!!! You just
for this experience.’ had to feel the energy in the room in order to understand
• ‘A unique experience and approach to vocal development how powerful this experience was for everybody, patients,
and requires lateral thinking and helps as a result and not children performers and audience. Many congratulations to
only the feeling of rhythm but also understanding of the all involved. . .’
mechanics, aiding breathing control.’
• ‘I was very impressed, particularly by the kids. The audience
participation was a good idea—perhaps more of that in DISCUSSION
future.’
• ‘This was an inspirational and informative event. The This work involved a small group of laryngectomees and
concept was so simple yet so uplifting. Thank you for the a novel approach to creative voice rehabilitation and
opportunity to hear patients, professionals, young people, development within a supportive and intimate environment.
and the public share in making amazing music together.’ This reinforced the work of patients with voice professionals
• ‘This charity gives patients such hope that where they are and encouraged an exploration of the patients’ voices through
now, does not always have to be where they stay, they are beatboxing. It also involved a final public performance in

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Moors et al. Beatboxing After Laryngectomy

such a secondary and tertiary gain for all participants anecdotally

is of significant note.
The audience in the final public performance was very
receptive to the interaction of the young participants with the
laryngectomees, the background information and introductions,
and the performances. This is also echoed in the written feedback
offered, some of which is presented above.
FIGURE 5 | A whip or slapstick. These pictures invite the participant to The youth and their parents involved in the project not
explore a laminal postalveolar click. By changing the size of the displayed
only found their participation to be rewarding but also reported
picture, they must react accordingly with volume control. This way, they learn
to control the tongue pressure and release in combination with mouth opening enjoying being active participants in and contributors to
in order to influence the volume of the sound. Such helps to practice using the public education and engagement; they reported learning a
involved articulators, including mainly the tongue. lot about the actual condition and also commented about
being happy and proud to share their experience with the
friends and family they had invited. Further, some offered to
front of a broad audience. A major challenge for an activity become more involved with charitable work. This approach
that involves such an eclectic group of individuals is the of workshops, wherein the patient and target groups are
vulnerability to absences and, unfortunately, three of our interacting, seemed to be an effective way to explain and
patient group became very ill and were unable to participate experience the impact of a condition. It certainly has inspired
during the period in which the described workshops took the research group and non-profit organization Shout at Cancer
place. For the same reason, we were unable to include to identify an interest in the development of this model further
someone with E speech in this group, although we had and to organize workshops in different locations and/or with
planned to do so. different target groups. This model is likely to be suitable
Beatboxing is a vocal art that is popular amongst a younger for different types of conditions and these outcomes may
audience, and to introduce it to an older patient group (mean be transferable to a wider patient and/or participant group;
age of 65 years) was initially, as expected, welcomed with some thus, we believe that it is worthy of further exploration.
reservation. This is perhaps also reflected in the somewhat We note this is obviously something that requires future
conservative scoring that some laryngectomees offered when systematic scrutiny.
asked to rate their experiences. However, the laryngectomy The patients seemed to have a stimulating effect on each
group responded well, overall, to the proposed exploration and other; as soon as one of them appeared to have mastered
exercises during the workshops. The recorded feedback was a certain technique or sound, the others found it easier to
positive; the participants liked it, and it made them approach imitate. Even so, there was variability in the produced sounds
their voice in a different way, improving voice awareness and skills. We acknowledge that this was a very limited group
and work on their pronunciation. All participants reported of patients (n = 9 in total), but the positive outcomes and
their engagement in this project has had beneficial effects on constructive interactions between patients suggest the need
their phonation as well as their breathing and the control of to further explore the use of workshops within a group
support mechanisms. context/environment. This experience suggests further research
In order to allow the patient group to have more time for into the use of more experienced laryngectomy speakers in the
exploring possible sounds systematically and to start developing voice recovery of patients who have recently had a laryngectomy
their basic skills, we only introduced the young coparticipants would be worthwhile.
in the last two sessions. The young participants picked up skills Furthermore, we discovered that these workshops demanded
very quickly, with some exceeding the expected level of basic great concentration and that the exercises could often be tiring.
beatboxing techniques. In future workshops we will need to factor in additional time for
Although none of the young participants had been exposed resting, relaxation and recovery.
to the laryngectomy voice or even heard of the condition before, The alaryngeal participants were encouraged to allow some
they were intrigued and not intimidated, exhibiting an openness time for practice at home between workshops and in preparation
toward the patients. They were attentive during the introduction for the final public performance. In reality, some of the
and the more detailed explanations about the layered impact participants reported they had not performed any alone. When
after laryngectomy. During the workshops, both patients and asked why, they stated that not only are the group sessions
participants interacted smoothly with each other. The young a social activity that they enjoyed but also these sessions
people asked questions freely and reacted in a collegial and made it easier for them to perform these exercises. They
respectful manner when the laryngectomy group was struggling reported that they did not feel incentivized to practice on
or had to do a certain exercise at a slower pace. We included their own, as it was the group experience that acted as the
the young participants in introducing the small topics presented motivation catalyst. Meanwhile, others reflected that they did
during the performance. This motivated them to interact with find time to do the rhythmical exercises because they were
the patient group even more closely and also to prepare easily built into any type of music they are listening to, and
and perform background information searches. The societal they found themselves beatboxing along to many songs on
awareness benefit to this project was not a prime objective, but numerous occasions.

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Moors et al. Beatboxing After Laryngectomy

To facilitate individuals’ exercising, we developed and made need to be context sensitive, and we do not foresee a randomized
available relevant demonstration videos and pictures, based on control trial as applicable within the present paradigm.
the outcomes of the workshops. We aim to create more exercises Albeit a small number of participant laryngectomees, as a
at different levels of difficulty and interaction and integrate these willing subset of what we believe to be the world’s only organized
in an online platform. The effectiveness of such a design is and systematically practicing and performing alaryngeal vocal
currently being assessed with further empirical research. This ensemble, we found that beatboxing is an exciting, pluralistic,
research will hopefully allow the team to offer support to inclusive and very engaging way to introduce a safe synergistic
individuals and groups and is hoped to also involve sessions environment within which laryngectomees engaged in creative
for patients with varying levels of experience but also voice activity using their novel vocal instruments. These activities were
professionals that wish to support laryngectomees. Similar online reported to offer greater benefits in allowing the laryngectomees
services could help to improve accessibility to health care (in this to further develop their breathing as well as support-structures
case, voice recovery) in both developed and developing countries control whilst engaging in meaningful music-making.
(Guo and Li, 2018).

DATA AVAILABILITY STATEMENT

CONCLUSION
The datasets generated for this study are available on request to
Laryngectomy affects a relatively small and scattered population the corresponding author.
with a higher incidence in the developing world, where
there may be limited access to health care and support.
The operation has a negative psychosocial impact, leading to ETHICS STATEMENT
high percentages of depression and social isolation among
An ethics approval was not required as per the authors’
the affected population, where communication issues play
Institutions’ guidelines and national regulations. This was
an important role.
also confirmed by the joint Medical Research Council (MRC)
This public engagement project of beatboxing after
and United Kingdom National Health System (NHS) Health
laryngectomy used a series of workshops and a final public
Research Authority online ethics assessment tool (http://
performance not only to increase awareness about throat cancer
www.hra-decisiontools.org.uk/ethics/index.html). Nevertheless,
and its impact on people’s lives but also to explore the potential
written informed consent was obtained from all adult
benefits of creative group participation of laryngectomees and
participants and from the parents/legal guardians of non-adult
to rehearse whether this has the potential to inform future
participants/performers.
research and practice.
We explored the implementation of beatboxing techniques
into speech rehabilitation after laryngectomy. Both the research
evidence from the literature and our somewhat limited empirical
AUTHOR CONTRIBUTIONS
findings during the explorative workshops are supportive of TM and EH designed the research project, and conducted the
the inclusion of beatboxing techniques in rehabilitation of the workshops and public engagement performance. TM developed
voice after laryngectomy. The overwhelmingly positive feedback the materials and drafted the manuscript. EH designed the
that we have received suggests there is value in presenting feedback instrument, collected and analyzed the feedback data,
how we structured our work and what methods we employed performed the further edits, and finalized the manuscript. All
so that future research can build upon the significant effort other authors offered feedback and comments for the completion
invested in developing the essential materials, methods and of the final manuscript.
media needed for this work. We adopted and translated
some of our findings into educational materials and exercises
supported by pictures and video tutorials. These materials are FUNDING
already being accessed by patients, carers and practitioners
and are assets of a currently under development interactive This study was supported by a UCL Culture Beacon Bursary.
technology platform that is intended to increase accessibility
in voice recovery.
Clearly, there is a need for future systematic research within ACKNOWLEDGMENTS
this context if a musico-therapeutic curriculum were to be
established and/or if a battery were to be developed for the The authors are grateful to UCL Culture, Shout at Cancer,
assessment of the effectiveness of such work as ‘intervention.’ Marv Radio (beatboxer), Laverne Williams (soprano), Claire
Given the particular demographic and specific challenges that Holmes (illustrator), Edoardo Brighenti (video production) and
laryngectomees face on a daily basis, a future research design will all project and final event participants.

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Moors et al. Beatboxing After Laryngectomy

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Mental disorders and psychosocial support during the first year after total reproduction is permitted which does not comply with these terms.

Frontiers in Psychology | www.frontiersin.org 13 January 2020 | Volume 10 | Article 2854