Voice Ch. 7: Vocal Rehabilitation – Flashcards
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What makes voice therapy is a highly individualized process?
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- different etiologic factors - background history - certain voice demands - medical complexities - occupational and social issues - motivation
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What is the goal of voice therapy?
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To restore the best voice possible
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What does the best voice possible focus on?
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- functional outcomes (for purpose of emplyment opportunities) - social interactions - activities of daily living
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What should voice program reeducate patient on?
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How to effectively and efficiently use the voice and eliminate the reformation of the voice disorder/pathology
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How does a voice therapy session begin?
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- describe different factors (on next card) - measure motivation for therapy - discuss a timeline - home practice materials
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What kinds of things should be described in beginning of voice therapy session?
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- normal anatomy and physiology - etiologic factors - correlate etiology and vocal symptoms - impact on vocal fold function
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When do you terminate therapy?
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1. resolution of the vocal pathology (typically not the case) 2. patient satisfaction with voice outcome (common) 3. reimbursement/insurance issues
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Treatment Efficacy
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Voice therapy techniques should be selected based on empirical evidence for their use and effectiveness rather than their popularity or promotion (EBP)
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Factors contributing to a successful therapy outcome (6)
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- agreement of the therapy process - willingness to change - elimination of other medical problems - development of realistic expectations - consideration of other health problems - development of a trusting rapport between clinician and patient
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Therapy Approaches (7)
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- Voice rest and modified voice rest - vocal hygeine - symptomatic voice therapy - psychogenic voice therapy - psychologic voice therapy - electric therapy - combined modality
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Complete voice rest
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Elimination of ALL vocal fold contact
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Complete voice rest does not aid in?
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the process to reprogram the patient's behaviors
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Complete voice rest is useful for...
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the healing process. However, studies suggest wound healing relies on vocal activity
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Modified voice rest
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elimination of excessive voice use, using the voice only when absolutely necessary and in a therapeutic manner - duration should be patient specific
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Modified voice rest takes into account...
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pathology, vibratory characteristics, lifestyle, and personality factors
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Vocal hygiene goal
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Goal is to eliminate any behaviors that cause trauma to the structural health and function of the VFs - focuses on pt education - used with another form of treatment
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Symptomatic voice therapy focus?
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Focus is on modifying abberant vocal symptoms observed by the pt or SLP, such as: high pitch, breathy voice, or hard glottal attack
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Symptomatic voice therapy: hierarchical pattern
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1. Pt identifies the behavior that needs to be eliminated or modified 2. Stimulate the desired target behavior by using facilitating techniques
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Facilitating Techniques List (25)
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- auditory feedback - change of loudness - chant talk - chewing - confidential voice - counseling - digital manipulation - elimination of "abuses" - establishing a new pitch - focus - glottal fry - head positioning - hierarchy analysis - inhalation phonation - laryngeal massage - masking - nasal/glide stimulation - open mouth approach - pitch inflection - redirected phonation - relaxation - respiration training - tongue protrusion /i/ - visual feedback - yawn-sigh
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Psychogenic: Define
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- vocal habits due to emotional, occupational, or social stresses * serious cases should be referred for a psychiatric evaluation
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Psychogenic: How can voice pathologist help?
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Voice pathologist can help the pt. remediate the emotional disturbances associated with the onset or maintence of the condition
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Physiologic voice therapy
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direct exercises are used to activate the laryngeal muscle and work other subsystems, such as respiratory and supraglottal systems
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Examples of physiologic voice therapy
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- vocal function exercises - lessac-madsen resonant voice therapy - lee silverman voice treatment - inspiratory and expiratory muscle strength training
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Vocal Function Exercises: Used for pts with?
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- Developed by Joseph Stemple - used to help patients with hyper or hypo functional voice disorders
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Vocal Function Exercises: Protocol/Steps
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Steps to the program are: - vocal warm up - pitch glides - prolonged phonation of /o/ at selected pitches
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Lessac-madsen resonant voice therapy: Used for pts with?
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Used to help adolecent and adult voice pts with hypo and hyperfunctional voice disorders - developed by Katherine Verdolini Abbott
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Lessac-madsen resonant voice therapy: Target
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Target is for the pt to use the least amount of respiratory effort and impact stress on the VFs
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Lessac-madsen resonant voice therapy: Duration
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30-45 minute sessions once or twice a per week for 4-8 weeks
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LMRVT Protocol: 1st therapy session
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First therapy session: collect pt case history data and educate pt about voice care
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LMRVT Protocol: 2nd therapy session
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Introduce "resonant voice basic training gesture (RV BTG)"
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Resonant voice basic training gesture (RV BTG)
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- simple sounds: mmmmmm - words: moon, mention, etc - phrases: the machine is broken - chant: meet me peter, meet me - regular conversation: in quiet and short distances
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Lee Silvermal Voice Treatment: goal
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- Goal is to increase loudness by increasing effort and coordination during speech production
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Lee Silvermal Voice Treatment: Protocol
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4 times per week for 4 weeks; 1 hour sessions - certification required
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LSVT relies on....
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relies on memory, learning and reliance on self cuing and self-regulating
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Lee Silvermal Voice Treatment: Used primarily with?
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Parkinsons disease
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Laryngeal Relaxation with circumlaryngeal massage and re-posturing technique: Step 1
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1. from the thyroid notch, move superiorly finding the hyoid bone and place direct pressure on the two major cornu of the hyoid bone
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Laryngeal Relaxation with circumlaryngeal massage and re-posturing technique: Step 2
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2. from the thyroid notch move just superiorly, finding the superior cornu of the thyroid notch and apply pressure
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Laryngeal Relaxation with circumlaryngeal massage and re-posturing technique: Step 3
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3. from the thyroid notch move laterally to feel along the anterior side of the sternocleidomastoid muscle, then move up to palpate the submandibular muscles
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Laryngeal Relaxation with circumlaryngeal massage and re-posturing technique: Step 4
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4. find the thyroid notch and apply traction, pulling the larynx down during vocalization to determine if there is an improvement in voice quality ** If voice quality significantly improves then laryngeal repositioning may be a ley factor in remediating the pts dysphonia
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Laryngeal Relaxation with circumlaryngeal massage and re-posturing technique: Step 5
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5. apply manual tension reduction using the clinicians or the pts fingers
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Laryngeal Relaxation with circumlaryngeal massage and re-posturing technique: Step 6
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6. pressure is applied in a circular motion with downward pressure
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Expiratory muscles strength training: based on?
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based on the notion that strength of the skeletal muscles such as limb muscles, occurs fairly rapidly due to neural mechanisms and eventual muscle hypertrophy as training progresses
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Expiratory muscles strength training: technique
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use a pressure threshold device to blow forcefully through (can be calibrated up to a pressure range of 150cm h2o) * similar to increasing weight being lifted during exercises
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Expiratory muscles strength training: Patients/Population
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pediatrics and adults with hypofunctional, hyperfunction and neurogenic populations
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Eclectic Therapy: Define
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uses multiple behavioral therapy orientations to address pts care
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Combined modality
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a combination of treatment modalities, such as: behavioral, pharmacologic, and surgical interventions
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Special Cases (4)
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- paradoxical vocal fold dysfunction (PVFD) - abductor spasmodic dysphonia (ABSD) - adductor spasmodic dysphonie (ADSD) - voice therapy for school-age children with voice disorders
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Management of PVFD: Behavioral appraoches
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- acknowledge sensations and emotions - establish good breathing pattern and teach voluntary control when airway is obstructed - teach inspiratory & expiratory breath coordination and self-awareness of breathing - teach "wide open throat" breathing
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Management of PVFD: Psychotherapy approach
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aim to retain psychiatric symptoms without needing to use PVFD as a coping syndrome
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Management of ABSD
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1. Botox 2. inject posterior cricoarytenoid muscle
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Management of ADSD
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- surgical (modify mechanisms of phonation) - chemodenervation (botox to denervate muscle) - alternative (acupuncture, chiropractic manipulation) - behavioral (relaxation, conventional voice therapy) - combined modality approaches
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Semi-occluded vocal tract exercises: Purpose
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Purpose of these exercises is to improve VF adduction, vocal registration, and epilarynx tube narrowing in order to acheive the best acoustic power transfer from the glottis to the lips
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Semi occluded vocal tract: various forms
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- lip trills - tongue trills - bilabial fricatives - humming - phonation into tubes or straws
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Semi occluded vocal tract: what have recent studies found?
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that semi-occlusion in the front of the vocal tract (at the lips) heightens source-tract interaction by raising the mean suprglottal and intraglottal pressures
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Voice therapy for school-age children: pediatric models have focused on?
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eliminating vocal behaviors that are not conductive to vocal health (do and do not) - rarely successful!
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Voice therapy for school-age children
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- train child to make sounds more therapeutically - voice therapy occurs in school settings for most children with voice disorders (IDEA)
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Biofeedback techniques
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- feedback of biological information to gain control of bodily processes that normally cannot be controlled voluntarily
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Biofeedback techniques: examples
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- electromyography - plethysmography
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Voice Outcomes
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the outcomes that are selected for making judgement about improvements in vocal performance or QOL with intervention needs to be selected carefully based on validity and reliability of the measure
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Facilitation Techniques: Auditory Feedback
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recorded sample of pt's voice for pt to judge correct vs. incorrect production
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Facilitation Techniques: Change of loudness
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educates pt on how vocal loudness impacts VF vibration and modifies loudness
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Facilitation Techniques: Chant talk
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Used with hyperfunctional voice disorders; Words run continuously together without changes in stress or prosody; rhythmic talking
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Facilitation Techniques: Chewing
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Used with hyperfunctional voice disorders; facilitates greater mouth movements to improve oral resonance, reduce extrinsic laryngeal muscle tension and reduce vocal strain
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Facilitation Techniques: Confidential Voice
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Used with hyperfunctional voice; soft, east onset, relaxed voice
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Facilitation Techniques: Counseling
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helps pt explore consequences, instrinsic and extrinsic factors that relate to condition, refer pt for help with psychological issues
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Facilitation Techniques: Digital Manipulation
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Using physical pressure on the thyroid cartilage to reduce excessive extrinsic muscle contraction that minimizes laryngeal movement
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Facilitation Techniques: Elimination of Abuses
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identifying and eliminating behaviors that cause harmful effects
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Facilitation Techniques: Establishing a new pitch
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Slight alterations in vocal pitch to make sure pt not straining VFs
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Facilitation Techniques: Focus
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help pt generate a voice source that is optimal with regard to resonance
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Facilitation Techniques: Glottal Fry
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hyperfunctional voice disorders; can be used as a relaxing technique
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Facilitation Techniques: Head Positioning
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good posture; elevated chin position. Head turning used with unilateral VF paralysis by turning head to affected side to aid in VF adduction
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Facilitation Techniques: Hierarchy Analysis
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Help pt identify most stressful or anxiety provoking events, comparing situations that create a good or bad voice. Uses a relaxation strategy to reduce stress.
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Facilitation Techniques: Inhalation Phonation
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voice production on inspiration instead of expiration
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Facilitation Techniques: Laryngeal Massage
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massage larynx to reduce extrinsic laryngeal muscle tension and lower laryngeal position
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Facilitation Techniques: Masking
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using source of noise to elevate vocal loudness. Voice clarity my result
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Facilitation Techniques: Nasal/Glide Stim
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words predominated by nasals and glides used for those with hyperfunctional voice production. Relaxes articulators and optimizes nasal resonance
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Facilitation Techniques: Open mouth approach
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open mouth to reduce dampening of sound production and increase oral resonance
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Facilitation Techniques: Redirected phonation
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used for pts who are unable to produce any voice often due to excessive vocal strain.
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Facilitation Techniques: Relaxation
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Used to help pt reduce stress via relaxation
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Facilitation Techniques: Respiration Training
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Teach the pt to coordinate inspiratory and expiratory phases of voice production to optimize lung volumes for speech
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Facilitation Techniques: Tongue protrusion /i/
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minimize hyperfunction by posturing tongue for /i/. High tongue position helps reduce pharyngeal squeezing. Used ventricular hyperfunction/phonation.
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Facilitation Techniques: Visual feedback
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aid pts in identifying correct vs. incorrect voice production
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Facilitation Techniques: Yawn-Sigh
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Used with hyperfunctional phonation. Lowers position of larynx, widens pharynx, moves tongue forward and reduces extrinsic laryngeal muscle tension.
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Interventions can take the form of many therapies: Name 3 forms:
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1. behavioral 2. surgical 3. medical
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the best research design for defining the effectiveness of a treatment is:
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large randomized control trials
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Name 4 of the initial steps in the therapy process
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1. gauge pt motivation 2. empower the pt to take responsibility 3. provide pt with a timeline of the therapeutic process 4. develop home practice materials
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Define treatment efficacy
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how well the treatment effects the symptoms of a disorder in comparison to other standard treatments
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the target population for voice therapy includes any person who complains of a disturbance to the voice that results in?
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- impairment - disability - handicap
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a pt can contribute to successful therapy outcome by:
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taking responsibility for their condition and making a time commitment to the treatment process
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Name 4 factors of successful therapy outcomes that a clinician is responsible for:
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1. knowledge and skill of normal and disordered voice production 2. knowledge and skill of therapeutic process 3. compassion, understanding and empathy 4. counseling skills
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the voice pathologists role is to discern whether the voice symptoms are due to _____, ______, or _________ reasons, and it not, work toward helping the pt remediate the _______ disturbances associated with the onset or maintenance of the condition
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structural, physiologic, or neurophysiologic emotional
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give 3 examples of physiological therapy techniques
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1. lee silverman voice treatment 2. vocal function exercises 3. lessac-madsen resonant voice therapy
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The LVST program uses _________ as a trigger
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vocal loudness
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What are the 5 fundamental concepts that the LVST program is based on?
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1. thinking loud 2. high speech effort 3. intensive treatment 4. recalibrating loudness level 5. quantifying improvements
