ICF and Voice Assessment, Typical Voice Ax Components, Auditory Perceptual Tasks Flashcards
- Women and children, not usually men.
- Always 2 - bilateral
- When soft, voice clarity may improve on high pitch as vocal folds thin and stretch
- Can be treated with SP
- Hourglass shaped, incomplete closure of glottis
- Breathiness, roughness
Vocal nodules (an ICF Body Structures impairment - structure of the larynx s340)
-> Pitch range task (pitch glides) - if nodules are soft (newer?) voice clarity will improve as they’re stretched with vocal folds on high pitch, may be worse on low pitch
Vocal fold paresis - ICF?
Neurogenic voice disorder with structural impairment in the nervous system - Structure of Cranial Nerves (s1106)
[damage to recurrent laryngeal nerve]
What are body functions? (ICF)
Physiological functions of body systems (including psychological functions).
Voice b126 - Temperament and personality functions b152 - Emotional functions b310 Voice functions b3100 Production of voice b3101 Quality of voice
What are body structures (ICF)?
Anatomical parts of the body, such as organs, limbs and their components.
Voice s110 - Structure of brain s1106 - Structure of cranial nerves s340 - Structure of larynx s3400 - Vocal folds
Voice functions (ICF) relevant to voice impairments?
- Impairment with the production of voice of adequate and appropriate loudness (b3100)
- Good vocal qualities (b3101)
Emotional reaction to dysphonia:
- under temperament and personality functions (b126)
and/or
-Emotional functions (b152)
What is ‘Activity’ (ICF)?
The execution of a task or activity by an individual.
[Activity limitation]
Voice: The constraints imposed on voice activities.
Voice activities (ICF) relevant to voice impairments?
[Dysphonic individuals with vocal fold paralysis (neurogenic) experience greater extents of voice activity limitations than those with functional voice disorders associated with phonotrauma. (Ma et al., 2007)]
Limitations in…
- speaking (d330)
- Having conversations with others (d350)
- calling someone on the telephone (Using telecommunication devices, d3600)
- Socialising with friends and colleagues (Socialising, d9205)
For professional voice users:
- Acquiring, keeping and terminating a job (d845)
- Renumerative employment (d850)
Environmental factors (ICF) (e)
- Products and technology
- Natural environment and human-made changes to environment
- Supports and relationships
- Attitudes
- Services, systems, and policies
Personal factors (ICF)
Exist before the onset of the disorder.
Can influence how the individual reacts to the limitation.
[gender, race, age, coping styles, profession, personality, past and current experience]
An effective clinical assessment should comprehensively document…
…the impacts of dysphonia on the individual.
Ma et al., 2007
What is the main assessment of body functions impairments of dysphonia?
Auditory-perceptual evaluation (regarded as the gold-standard in documenting voice impairment severity).
(Ma el at., 2007)
What are the perceptual measures of voice measured on Cape-V, usually filled out during case history, conversation or reading the Rainbow passage?
–> Measures of body functions
*Overall severity
*Roughness
*Breathiness
*Strain
*Pitch
*Loudness
*Resonance
[Additional: Fry, Pitch breaks, Phonation breaks, Pitch instability, Diplophonia, Falsetto, Asthenia, Aphonia, Tremor, Wet/gurgly]
Why are objective instrumental assessments including acoustic voice analysis, aerodynamic measurements, and physiological measurements (e.g. electroglottography, electromyography) often included in the clinical Ax battery…?
To supplement the subjective auditory-perceptual evaluation of voice. [Which primarily measures ICF function]
When assessing ICF Body Functions impairment in voice, how do we ensure Ax procedure reflects true vocal fold functioning, and therefore realistically Ax impairments on body functions?
Evaluate naturalistic speech material ie monologues, vocal qualities in actual communication situations (i.e. classroom)
Which part of the Ax battery for voice assesses the extent of activity limitations and participation restrictions experienced by the patient?
- Case history (Ask: to what extent is your daily life (or job, etc) limited or restricted by your voice problem?
- PROMs
Under the ICF, what do performance and capacity refer to, under the Activities and Participation component?
Capacity: The ability of the individual to carry out a task under standardised environments such as clinic rooms.
Performance: Describes how the individual functions under the actual life situations.
Which part of the Ax battery for voice assesses the influence of environmental factors, either as communication barriers or facilitators, on the dysphonic individual’s functioning?
- Case History
* Clinical observations.
Which part of the Ax battery for voice assesses the influence of personal factors on the dysphonic individual’s functioning?
- Case History
* Clinical observations
When would you conduct a screening test?
When a voice disorder is suspected. It may be triggered by concern from indiduals, parents, teachers, or health care providers. When deviations from normal voice are detected during screening, further evaluation is warranted.
ASHA Assessment Guidelines (Voice) - Typical Components
- Case History
- Self-Assessment
- Oral-Peripheral Exam
- Assessment of Respiration
- Auditory-Perceptual Assessment
Case History (Typical components for voice Ax - ASHA Assessment Guidelines)
- Individual’s description of voice problem, including onset and variability of symptoms
- Medical status and history, including surgeries, chronic disorders, and medications
- Previous voice treatment
- Daily habits related to vocal hygiene
Self-Assessment (PROMs)
Typical components for Voice Ax - ASHA Assessment Guidelines
Individual’s assessment of how voice problem affects
- emotions and self-image; and
- ability to communicate effectively in everyday activities and in social and work settings (e.g., Hogikyan & Sethuraman, 1999; Jacobson et al., 1997; Ma & Yiu, 2001).
Oral-Peripheral Exam
Typical components for Voice Ax - ASHA Assessment Guidelines
- Assessment of structural or motor-based deficits that may affect communication and voice, including strength, speed, and range of motion of oral musculature
- Assessment of symmetry and movement of structures of the face, oral cavity, head, neck, and respiratory system during rest and purposeful speech tasks
- Testing of mechano-sensation of face and oral cavity
- Testing of chemo-sensation (i.e., taste and smell)
- Assessment of laryngeal sensations (dryness, tickling, burning, pain, etc.) and palpation of extrinsic laryngeal musculature, as indicated
Assessment of Respiration
Typical components for Voice Ax - ASHA Assessment Guidelines
- Respiratory pattern (abdominal, thoracic, clavicular)
- Coordination of respiration with phonation (breath-holding patterns, habitual use of residual air, length of breath groups)
- Maximum phonation time (MPT; Dejonckere, 2010; Speyer et al., 2010)
- s/z ratio to assess for glottal insufficiency, which may be indicative of laryngeal pathology (Eckel & Boone, 1981; Stemple et al., 2010)
Auditory-Perceptual Assessment
Subjective Assessment Based on Clinical Impressions of the SLP
(Typical components for Voice Ax - ASHA Assessment Guidelines)
Voice Quality
*Roughness
*Breathiness
*Strain
*Pitch (perceptual correlate of fundamental frequency)
*Loudness (perceptual correlate of sound intensity)
*Overall severity
*Additional perceptual features
Diplophonia, aphonia, pitch instability, tremor, vocal fry, falsetto, wet/gurgly
(Kemper, Gerratt, Abbott, Barkmeier-Kraemer, & Hillman, 2009; ASHA, 2002; ASHA , n.d.)
Auditory Perceptual Assessment - Voice Quality
Strain
—perception of excessive vocal effort
ASHA, n.d.
Auditory Perceptual Assessment - Voice Quality
Roughness
-perceived irregularity in voicing source
Auditory Perceptual Assessment - Voice Quality
Breathiness
—audible air escape in voice
Auditory Perceptual Assessment - Voice Quality
Pitch (perceptual correlate of fundamental frequency)
—deviations from normal relative to age, gender, and referent culture
Auditory Perceptual Assessment - Voice Quality
Loudness (perceptual correlate of sound intensity)
—deviations from normal relative to age, gender, and referent culture
Auditory Perceptual Assessment - Voice Quality
Overall severity
—global, integrated impression of voice deviance
Auditory Perceptual Assessment - Voice Quality
Additional perceptual features
Diplophonia, aphonia, pitch instability, tremor, vocal fry, falsetto, wet/gurgly
Auditory Perceptual Assessment - Resonance
- Assess resonance quality (normal, hyponasal, hypernasal, cul-de-sac).
- If abnormal, assess stimulability for normal resonance.
- If normal, evaluate the focus of resonance (oral, pharyngeal/laryngeal, nasal).
Auditory Perceptual Assessment - Phonation
- Voice onset/offset (e.g., delayed voice onset; quality of voice at onset)
- Ability to sustain the voice to achieve appropriate phrasing during speaking
- Ability to demonstrate strong and consistent rate of vocal fold valving during diadochokinesis
Auditory Perceptual Assessment - Rate
Deviations from normal relative to age, gender, and referent culture
Instrumental Assessment
ASHA, n.d. https://www.asha.org/practice-portal/clinical-topics/voice-disorders/#collapse_5
- Laryngeal Imaging
- Acoustic Assessment
- Aerodynamic Assessment
Instrumental Assessment - - Laryngeal Imaging
Measures of structure and gross function (using videoendoscopy) and measures of vocal fold vibration during phonation (using videostroboscopy)
(ASHA, n.d. https://www.asha.org/practice-portal/clinical-topics/voice-disorders/#collapse_5)
-
Videolaryngoendoscopy
*Vocal fold edges—appearance of superior vocal fold edges during abduction
*Vocal fold mobility—movement of vocal folds toward and away from midline at level of cricoarytenoid joint during laryngeal diadochokinetic task
*Supraglottic activity—degree of compression of supraglottic structures during sustained phonation
- Videolaryngostroboscopy
- Regularity—consistency of successive glottic cycles
- Amplitude—lateral movement of the vocal fold medial plane
- Mucosal wave—independent lateral movement of mucosa over vocal fold
- Left/right phase symmetry—symmetry of vocal folds (opening, closing, maximum lateral–medial excursion) during glottic cycle
- Vertical level—level difference in vertical plane between vocal folds during maximum closed phase of glottic cycle
- Glottal closure pattern—glottal configuration during maximum closure
- Glottal closure duration—relative proportion of glottal cycle in which glottis is closed
Instrumental Assessment - Acoustic Assessment
Objective measures of vocal function related to vocal loudness, pitch, and quality
(ASHA, n.d. https://www.asha.org/practice-portal/clinical-topics/voice-disorders/#collapse_5)
Acoustic Assessment
-Vocal amplitude (Habitual - reading passage, Minimum and maximum vocal SPL (dB) - softest and loudest sustainable phonation
Vocal frequency
- Mean vocal f0 (Hz)—average of the estimates of the f0 for acoustic signal recorded during connected speech (standard reading passage)
- Vocal f0 standard deviation (SD; Hz)—SD of the estimates of the f0 for acoustic signal recorded during connected speech
- Minimum and maximum vocal f0 (Hz)—f0 values for the lowest and highest pitched sustainable phonations
Vocal signal quality
-Vocal cepstral peak prominence (CPP; dB)—relative amplitude of the peak in the cepstrum that represents the dominant rahmonic of the vocal acoustic signal (sustained vowels and connected speech samples)
Instrumental Assessment - Aerodynamic Assessment
Measures (using noninvasive procedures) of glottal aerodynamic parameters required for phonation
(ASHA, n.d. https://www.asha.org/practice-portal/clinical-topics/voice-disorders/#collapse_5)
*Glottal airflow
-Average glottal airflow rate (L/sec or mL/sec)—estimated from oral airflow rate during vowel production
*Subglottal air pressure
-Average subglottal air pressure (cm of water [cmH2O] or kilopascals [kPa])—estimated for intraoral air pressure produced during repetition of stop consonants in syllable strings
*Mean vocal SPL and f0
—extracted from simultaneously recorded acoustic signal; facilitates interpretation of airflow and air pressure measurements
Comprehensive Assessment for Voice Disorders –>
Assessment may result in
(ASHA, n.d. https://www.asha.org/practice-portal/clinical-topics/voice-disorders/#collapse_5)
- Diagnosis of a voice disorder;
- Clinical description of the characteristics and severity of the disorder;
- Statement of prognosis and recommendations for intervention;
- Identification of appropriate treatment or management options; and
- Referral to other professionals, as needed.
Multi-dimensional Assessment
Voicecraft, 2020
SUBJECTIVE
- Case Hx
- Self-report Tools (screeners, PROMs)
- Auditory-Perceptual Rating
- Functional Tasks
- Visual Imaging of Larynx
OBJECTIVE
- Acoustic Analysis
- Airflow
- Electrophysiological
Which questions need to be answered by the end of the Case Hx interview:
- Does a problem exist?
- What it it’s severity?
- What is the impact on QoL?
- What is the etiology of the problem?
- What is the likelihood and motivation for change?
- What is therapy likely to accomplish?
- Is there a need for further referral?
- Recommendations for therapy?
CAPE-V
Kempster, Gerratt, et al., 2009
Why is the CAPE-V a good Auditory-perceptual evaluation of voice tool?
- ASHA developed
- Uses consensus terminology (there is no common terminology for descriptions of voice quality)
- Used in a lot of research, so patient data can be compared with the research data
CAPE-V sentences
Allow us to hear how the voice sounds across different phonemically loaded contexts. [vowel onset, aspirant onset, nasals, mostly voiced, glides, voiceless plosives]
How to get a spontaneous speech sample using CAPE-V (Kempster, Gerratt, et al., 2009)
Ask: “Tell me about your voice problem” or “Tell me how your voice is functioning.”
Which 3 CAPE-V (Kempster, Gerratt, et al., 2009) tasks are used to rate voice quality?
- Sustained vowels /a/ and /i/ for 3-5 seconds
- CAPE-V sentences
- Spontanous speech in response to “Tell me about your voice problem” or “Tell me how your voice is functioning.”
- -> Can also use Case Hx Interview and reading of “The Rainbow Passage.”
What are the parameters of voice quality that are rated upon completion of:
- Sustained /a/ and /i/ 3-5 sec
- CAPE-V sentence production
- Spontaneous speech in response to “Tell me about your voice problem.”
CAPE-V (Kempster, Gerratt, et al., 2009)
- Overall Severity
- Roughness
- Breathiness
- Strain
- Pitch
- Loudness
- Lines if you want to give a numerical rating on above
- Resonance
- Note additional features (diplophonia, fry, falsetto, asthenia, pitch instability/breaks, phonation breaks, tremor, monotone, voice arrests, wet/gurgly)
What does C/I mean on the CAPE-V?
Kempster, Gerratt, et al., 2009
Consistent / Intermittant (circle one)
What scale is used on ratings of voice quality in the CAPE-V?
(Kempster, Gerratt, et al., 2009)
Linear scale 0-100
can make it a score/100
4 types of resonance
- Normal
- Hypernasality (air escaping through nose)
- Hyponasality (blocked nose sound)
- Cul-de-sac (muffled - like the sound can’t escape the vocal tract)
Why should I rate voice quality on connected speech, rather than a sustained vowel?
Prolonged vowel will be rated more severely than connected speech –> want the rating to reflect the way a person uses their voice to more accurately determine functioning and affect in real use.
How do we make COMPARATIVE perceptual judgements about our patient’s voice quality?
Record them reading The Rainbow Passage and CAPE-V sentences each time they come in.
