Voice- Approaches in therapy – Flashcards
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Programmatic approaches
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Lessac Madsen Resonant Voice Therapy (LMRVT) Vocal Function Exercises (VFE) Phonation Resistance Training Exercises (PhoRTE) Circumlaryngeal Massage (CLM) Lee Silverman Voice Treatment (LSVT)
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Other approaches
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Semi-occluded vocal tract exercises (SOVT) Confidential voice Flow phonation Conversation training therapy (CTT) Respiratory retraining exercises
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Resonant voice therapy (RVT)- creators
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Performing Arts: Arthur Lessac SLP's: Daniel Boone & Martin Cooper Katherine Verdolini
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RVT goal
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To achieve strongest, cleanest voice with least effort and impact between the VF's To minimize injury
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Rationale of RVT
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With RV: VF's are barely ad/abducted Best posture for strongest, clearest voice o/p Least amount of impact stress Least amount of lung pressure
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lessac-madsen resonant voice therapy (LMRVT) basics
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Systematic voice therapy program 8 sessions Key: sensory processing and imagery Feeling, hearing, and seeing: skill acquisition; not mere biomechanics
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LMRVT how to
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Key: voice produced with emphasis on forward focus Feel vibratory sensations Negative practice
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LMRVT approach
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Basic resonant voice training gesture- humming ("m") Other sounds: "n", "ng", "z", "v" Transition to: words, functional phrases Loudness: m.......M Conversation
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RVT efficacy
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RVT has positive effects on voice quality, vocal fold vibration, VF closure, speaking flexibility, phonation effort, and functional communication. Hard attack was virtually eliminated. VF pathology, vibration pattern, and closure were improved.
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target population- RVT
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Hypo/ hyperadducted VF's during phonation Lesions, glottal incompetence, & functional voice disorders
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vocal function exercises (VFE) creators
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Bertram Briess Joseph Stemple
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goal of VFE
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To work with laryngeal muscles as in PT To increase bulk, strength and coordinated interaction of laryngeal muscles
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rationale of VFE
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Maximal prolongations: Strengthen and coordinate laryngeal muscles ? Coordination between laryngeal and respiratory muscles Pitch glides Cricothyroid and vocal fold muscles are strengthened?
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VFE how to
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Intensive: 8 to 10 sessions Approach- How to? Maximal vowel prolongations (/i/) - warm-up Pitch glides (high to low and low to high- on knoll) Sustain musical notes (Knoll: minus Kn) Resonant voice (m) ? Transfer ?
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target population VFE
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Hyperfunction (Lesions, MTD), Hypofunction (glottal incompetence- atrophy), & functional voice disorders, singers- typical voice functioning
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VFE efficacy
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studies on teachers, unilateral granuloma, singers, elderly men
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phonation resistance training exercise (PhoRTE) creator
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Ziegler & Hapner
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theory and goal- PhoRTE
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Lee Silverman Voice Treatment Voice Science Exercise Physiology Progressive resistance training for limb skeletal muscle atrophy Motor control and learning
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Rationale of PhoRTE
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High intensity exercises and progressive resistance training overload respiratory and laryngeal muscles in order to increase muscle strength and endurance Increases muscle activity- improving Ps, airflow and VF vibration
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PhoRTE how to
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Hold a continuous vowel /a/- strong voice Glide from low to high /a/ and high to low /a/ on the pitch range with a strong voice Call out functional phrases- high voice (over the fence) and a low (authoritative) voice
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Progression of PhoRTE
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Initial workload: Exercises are completed at 50-60% of the total vocal intensity range or 5 dB above the average vocal intensity, whichever is greater 2 sets of exercises with a 1 minute rest period in between During each set, each exercise is completed 8-10 times to the point of muscular fatigue Clinician increases the workload by 5 dB each week Goal: Patient can perform exercises at 20 dB above average vocal intensity (~80-90 dB) Post discharge: Three times a week, patient performs exercises #3 and #4 (no more than once a day)
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Target population PhoRTE
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Currently for hypofunction- Specifically Atrophy
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Circumlaryngeal massage (CLM) creators
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Dr. Arnold Aronson Dr. Murray Morrison Dr. Nelson Roy
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goal of CLM
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lower the larynx and to decrease supralaryngeal muscle tension Increase range of motion (ROM)
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Rationale of CLM
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Stretch muscle tissue Encourage local circulation with removal of metabolic wastes Relax muscle tension to produce more normal voice Alleviate pain and discomfort linked with muscle spasms Lowering laryngeal position promotes normal phonation
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effects of CLM
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Decreased laryngeal height and stiffness Increased mobility Increased range of motion Improvement in vocal effort, Quality and dynamic range
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CLM how to
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Assess patient's posture Place hand behind patient's head to stabilize Assess height of larynx and tension of laryngeal muscles Instruct patient to swallow and locate thyroid notch Instruct patient to swallow, locate thyrohyoid space with thumb and index finger moving posteriorly to locate major horns of hyoid Employ moderate pressure in a circular, downward motion from superior horns to thyrohyoid space Move larynx side to side Move fingers in downward motion toward thyroid cartilage and depress larynx
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Target population CLM
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Hyperfunction (Primary and Secondary MTD)
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Lee Silverman Voice Therapy (LSVT) creators
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Lorraine Ramig Cynthia Fox David McFarland
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goal of LSVT
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Loud voice in daily communication with a carry over and sensory recalibration
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Rationales and principles of LSVT
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Think loud, think shout Speech effort must be high Treatment must be intensive Patients must recalibrate their loudness level Improvements are quantified over time
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LSVT approach
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Intensive treatment One assessment session 16 treatment sessions- 4 times per week for 4 weeks
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LSVT how to
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DO WHAT I DO Daily tasks (25-20min) Loud /ah/- 12-15minutes Glide high to low and low to high on /a/- 10-12minutes Functional phrases- 5-10minutes Hierarchy - 25-30minutes Structured reading- 15-20minutes Off the cuff- 5-10 minutes Homework and carryover exercises- 5 minutes Sensory recalibration- embedded in tasks
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target population LSVT
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Parkinson's disease Other conditions (e.g., Cerebral palsy, multiple sclerosis, stroke, ataxia)
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confidential voice- creator
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janina casper
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confidential voice- goal
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To produce an easy, quiet, breathy voice
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confidential voice-rationale
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With easy, quiet, breathy voice VFs vibrate with small amplitude Less impact stress Less chances of injury
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confidential voice-how to
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Key Produce an easy, quiet, breathy voice To imitate speaking confidentially to someone at closer range NOT a whisper
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confidential voice- in practice
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Wh sounds/ words Look for quiet and easy voice Negative practice Fade away to strong, safe way of talking, when transitioning: Why?
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confidential voice- when to use
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Voice conservation Post-surgery VF injury (phonotrauma)
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flow phonation- creators and important names
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Casteel and Stone, 1983 (Stretch and flow) Stretch dropped Gauffin and Sundberg, 1989 Flow Phonation Gartner-Schmitt, McCallough
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flow phonation- goal
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Focus on the flow; airflow management
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flow phonation- rationale
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With flow: co-ordination of respiratory and phonatory systems Smooth, consistent airflow Easy voice: VFs less impact stress (although no evidence) Release breath holding/medial compression
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flow phonation- how to
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Airflow release Breathy phonation Flow phonation Articulatory precision Key: AIRFLOW
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flow phonation- in practice
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Sigh Negative practice Articulated airflow (ooh, wa..wa..; poo,loo); phrases Breathy phonation Flow phonation (add voice, but still maintain flow) Articulatory precision BIOFEEDBACK : Tissue, ease of phonation
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flow phonation- when to use
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Breath-holding Hyperfunction Lesions, MTD
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semi-occluded vocal tract (SOVT) exercises- important names
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Linklater, 1976- lip trills Nix, 1999, lip and tongue trills Titze, 2002, flow resistant straws
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SOVT- goal
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Efficient voicing Minimally touching vocal folds
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SOVT-rationale
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Heightened interaction between glottis and supraglottal tract Laryngeal lowering Widening of hypopahrynx Decreased PTP- less vocal fold adduction MFDR is maximized
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SOVT- how to
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Lip trills Tongue trills Kazoo Straw exercises Without phonation With phonation Pitch glides Humming a tune
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SOVT- when to use
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Laryngeal hyperfunction Lesions Glottal insufficiency Singers
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respiratory retraining- creators
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Christopher et al. 1983 Introduced a type of therapy that focused on increasing the activity of the abdominal muscles during inspiration and reducing the force of the oropharyngeal muscle groups Martin et al. 1987 Elaborated on the tx process with a 7 step approach that focused on controlling the exhalation phase using the abdominal muscles
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respiratory retraining- goal
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To improve laryngeal and respiratory coordination during breathing To keep VFs open during quiet respiration
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respiratory retraining- patient counseling and education
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(a.k.a. "slow direction") Review assessment results Educate patient on laryngeal and respiratory structures and the process of respiration Review PVFM symptoms Acknowledge patients' fears Discuss emotional issues and possible triggers
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respiratory retraining- behavioral approach
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Provide clients with specific exercises to help them cope with an attack Teach self awareness and good breathing patterns
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respiratory retraining- diaphragmatic breathing
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Use of Diaphragmatic Breathing Divert attention away from larynx Limit laryngeal through tension reduction exercises and focus on utilizing the diaphragm for breathing
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respiratory retraining- wide open throat breath
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Promote relaxation and openness of larynx Lips closed, tongue flat on floor of mouth, jaw gently released Diaphragm used for inhalation/exhalation Instruct client to: Inhale through nose or pursed lips Count (variable) Abdomen is out
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respiratory retraining- focus on exhalation
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Help client learn to release his/her breath Interrupt the holding reaction in neck, shoulders, and chest and gasping for inhalation breaths Instruct client to: Exhale through: Pursed lips /s/,/sh/, /f/ Through a straw Panting Rhythmic pulse on /f/, /s/ Count (variable) Abdomen is in
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respiratory retraining- increasing self awareness of breathing sequence
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Lead client in consciously experiencing each stage of the exhalation and inhalation process Include negative practice (i.e., awareness of incorrect breathing and effort in laryngeal area)
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respiratory retraining- interruption of effortful breathing
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Teach client that breathing is a natural process and not something that has to be "done" by them Focus on diaphragm rather than pushing from the laryngeal area Help client to trust the natural process of breathing
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respiratory retraining- tx protocol
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Tension reduction (i.e. tightening/releasing) exercises Inhale through nose or pursed lips Count (variable) Abdomen is out Exhale through: Pursed lips /s/, /sh/, /f/ Through a straw Pant Pulsing /s/ Count (variable) Abdomen is in
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respiratory retraining- strategies
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Visualization Smelling flowers, blowing out a candle, use a mirror Positioning Keep chest and shoulders still; relax jaw, tongue and lips Lay on the floor to prevent clavicular breathing Practice! Recommended 3-5 times/day Document occurrences/suspected triggers
