Voice Therapy-Treatment – Flashcards
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What is the goal of voice therapy?
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restore best vocal quality - individualization -cause of problem -maintaining factors -motivation -availability of TX -patient goals
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What are the basics of voice therapy?
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1. Simple explanation of normal voice production 2. talk about how the client's voice deviates from - educate them on how the voice is made - relate therapy tasks to how they will improve voice
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Steps of voice therapy-
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1. identify the problem- anatomically and physiologically 2. Consider abnormalities in eval to guide management 3. Trial therapy- diagnostic probes- to see how patient will respond to certain approaches 4. Involve a mixture of several different approaches to improve voice 5. Make sure the patient can hear and feel their voice 6. Building awareness- self monitoring 7. Hierarchical task- level to level 8. Feedback- auditory and visual 9. ***Model tasks 10. Clinician must continually reassess and adjust as needed
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What are the three voice therapy approaches?
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hygiene symptomatic phsyiologic
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Vocal hygiene
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Identifying abusive behaviors: throat clearing hydration reflux voice use patterns
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What should a clinician do while implementing vocal hygiene into a session?
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describe the physiologic effects of those behaviors on voice production mechanism help to modify or eliminate those specific behaviors
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Vocal hygiene recommendations
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-hydration -Substitution of throat clearing or coughing -Reflux management -Management of environmental -vocal rest
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vocal abuse vs. vocal misuse
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abuse- yelling, screaming, speaking against background noise, smoking, excessive talking or singing (especially when fighting cold/allergies), excessive crying or laughing, weight lifting with effortful grunts, breath holding misuse- speaking with hard glottal attack, singing excessively outside one's normal pitch range, increasing vocal loudness by squeezing the voice out of larynx, speaking at excessive intensity levels, cheerleading, speaking over time at an inappropriate pitch level, speaking or singing for excessive long periods of time
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Direct treatment is superior to vocal hygiene
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true
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Physiologic voice therapy
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therapy programs involving exercises or vocal maneuvers that address all three subsystems of voice production at once Improve relationship between: -respiratory support -laryngeal muscle strength, control and stamina -supraglottic modification of laryngeal tone/resonance
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What are the subsystems of voice production?
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respiration, phonation, resonance
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Why is treating the physiology critical?
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-diagnosis doesn't always match the symptoms, patterns and production -individualized responses to pathology
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What is the universal goal of voice therapy?
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to restore normal physiology and balance pattern of production
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What are the types of physiologic voice therapy?
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accent method, lee silverman voice therapy, resonant voice therapy, vocal function exercises, cup/bubble lax vox, phonation resistance training exercises (PhoRTE), stretch and flow phonation, conversation voice therapy
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Accent method-Smith accent method
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Based on pulsed abdominal breaths to facilitate glottal closure Addresses: appropriate air pressure and airflow, pitch, loudness, and timbre simultaneously,
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What does accent method do for patients?
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builds new respiratory/voice pattern from basic syllable intonations through conversation
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Stages of Accent Method:
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1. Rest breathing: optimize inspiration for speech, control and shape expiratory airflow, initiate abdominal muscle contractions in a smooth and accentuated manner 2. Abdomino-phonatory accents: Control of rhythm, strength and speech of the abdominal muscle contractions with phonation -Single voiced and voiceless fricatives ("sh") -Short voiceless fricative followed by long loud fricatives -Voice fricatives-z -2 syllable- relaxed breathy voice -3-4 syllables-full voice -5-6 syllables 3. Stabilization- increase dynamic range of voice and speech 4. Transfer to connected speech- practice optimal phrase length, pause location, duration and speech rate
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Lee Silverman Voice Treatment
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(designed for Parkinson's) increased effort targeting improved respiratory, phonatory, resonance, and articulatory systems Single Target- LOUD
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Resonant Voice therapy
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"resonant/front focused voice from basic phonatory gestures through conversations" -voice production in the "mask" of face -Oral vibratory sensation in context of easy phonation -hum sigh -REPETITION, REPETITION, REPETITION
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What does resonant voice therapy do?
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alters the configuration of the VF and muscles of the larynx, reduces the vibratory forces that can contribute to mucosal trauma, creating an optimal pressure in the vocal tract above the glottis and VF resistance to airflow * often used for MTD
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Steps of Resonant Voice Therapy
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1. Hum sigh- sustained sounds, glides, sirens- 10x 2. Hum sigh into vowels Ma-ma-ma, me-me-me, my-my-my, mo-mo-mo 3. Hum sigh into words Mine, main, maybe, man, moon, man, mean, mail 4. Hum sigh into phrases Me and you, maybe tomorrow, man and woman, my best friend 5. Hum sigh into sentences chanting with inflection Marvin made me make more money, No one knows Norman's nickname. 6. Hum sigh into your own phrases maintaining ease and quality
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Vocal Function Exercises
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Three component program -warm ups -pitch glides -sustained vowel phonation at selected pitches
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Vocal function exercise vs. resonant voice therapy
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Resonant- "correct" practice Vocal function exercise- systematic practice to increase bulk and strength of thyroarytenoid muscle and improve coordination of the multiple muscles of the larynx that must be co-activated for speech
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Vocal Function Exercise plan
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-twice in a row, two times per day -produced softly as possible with an easy onset, forward placement of th tone - focus on posture, breathing, placement and onset
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Vocal function exercise 1
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"Warm up" -sustain vowel sound "eee" for as long as possible middle C for women and lower than middle C for men Goal: 40 seconds without breaks
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Vocal function exercise 2
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"stretching exercise" -glide from your lowest to your highest note on the word "knoll" or on a lip/tongue trill -voice should be soft and forward Goal: no voice breaks
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Vocal function exercise 3
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"Contracting exercise" -glide from a comfortable high note to your lowest note on the word "knoll" or on a lip/tongue trill -Soft voice, forward focused Goal: no voice breaks
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Vocal function exercise 4
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"Low impact Adductory Power" -sustain the musical notes C-D-E-F-G each as long as possible on the word "ol" -lips should be rounded- sympathetic vibration should be felt on lips Goal: 40 seconds without breaks
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Cup/Bubble Lax Vox/Semi-occluded vocal tract
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aerodynamic building task aimed at improving ability to sustain phonation while speaking -widening the vocal tract during phonation and reduces tension in the vocal folds allowing gentle vibration -lengthens the vocal tract
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How does Cup/bubble lax- semi-occluded vocal tract work?
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starts with blowing air into cup of water without voice -add voice --sustain pitch --pitch glides -cup is eventually removed during voicing and phonation continues
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When is SOVT used?
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after surgery
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Phonation Resistance Training (PhoRTE)
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"Behavior voice lift" - similar to LSCT- patients are reminded to maintain "strong" voice throughout these exercises -combines both loudness AND pitch when producing phrase
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What is PhoRTE use for?
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age related changes to the vocal folds or voice
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PhoRTE therapy steps
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-Producing /a/ with loud maximum sustained phonation -Producing /a/ with loud ascending and descending pitch glides over the entire pitch range -Producing functional phrases using a loud and high (pitched) voice -Producing the same functional phrases using loud and low (pitched) voice
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Stretch-flow phonation/casper-stone flow phonation
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airflow management and is used for individuals with breath-holding tendencies -focus: steady outflow of air during exhalation-with breathy quality -for functional dysphonia or aphonia
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How is stretch-flow implemented?
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Using a hand/tissue to passively exhale, feel continuous airstream on hand/watch on tissue. Continue as above, adding voice. The vowel (ooooo) should be air filled and easy. The airstream should remain continuous, just as it is without voice. Feel vibration at the lips/energy of the sound of the mouth. -Sustain - 10x -Descending glide - 10x -Ascending glide - 10x -Siren - 10x Continue into words with continuous airflow- feeling buzz at the lips Continue into phrases Gradually discontinue use of "ooo" maintaining easy, continuous airflow
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Symptomatic Voice therapy
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modification of the deviant vocal symptoms or perceptual voice components - this therapy assumes voice improvement through direct symptom modification using a variety of voice facilitating techniques
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What are some deviant symptoms?
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pitch is too high or low voice is too soft or low breathy phonation use of hard glottal attacks or glottal fry
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Types of symptomatic voice therapy
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amplification, auditory masking, biofeedback, chant speech, confidential voice, posture, relaxation, yawn-sign, semi-occluded vocal tract (SOVT)
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Amplification
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microphones or other adaptive voices which increase volume, supportive augmentative communication, helps prevent vocal hyperfunction -Chattervox
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Auditory Masking
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for functional dysphonia, aphonia patient talks or reads passages aloud while wearing headphones with masking noise input
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Biofeedback
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provides clear and reliable feedback in response to alterations in voice production, thus facilitating improvements in pitch, loudness, quality, and effort (kinesthetic, auditory, or visual) -helps patients become aware of physical sensations with respect to respiration, body position, and vibratory sensation
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Chant speech
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rhythmic, prosodic pattern that serves as a template for spoken utterance
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Chewing
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vocal hyperfunction with observed reduced mandibular and/or labial movement and hard glottal attacks
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Confidential voice
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designed to reduce laryngeal/hyperfunction and increase air flow- starts with easy and breathy vocal quality and builds to normal voicing without decreasing airflow
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Semi-occluded vocal tract
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narrowing at any supraglottic point along the vocal tract in order to maximize interaction between vocal fold vibration and vocal tract and to produce resonant voice --straw phonation, lip trills
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posture and relaxation
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upright posture, low relaxed shoulders, head positioning
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Strategies for relaxation
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progressive muscle relaxation, visualization, deep breathing exercises, laryngeal massage
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redirected phonation
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most beneficial when the patient is having difficulties finding their voice - uses vegetative phonation or intentional voicing, then turns into speaking
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Examples of redirected phonation
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coughing, gargling, humming, laughing, playing the kazoo, singing, throat clearing, trilling, um-hmm
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Yawn-sigh
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reduces tension of vocal hyperfunction larynx is lower, pharynx is dilated, slight glottic opening
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How does yawn-sigh work?
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begin with yawn with easily, light voice- model to patient and have them demonstrate - start with saying words that begin with /h/ or with open-mouthed vowels - 1 word per yawn and then work your way up to 4, 5 - yawn can be dropped later and begin relaxed sigh
