Vocal Rehabilitation Flashcards
A combination of treatment modalities, such as: behavioral, pharmacological, and surgical interventions
Combined modality
Elimination of all vocal fold contact Does not aid in the process to reprogram the patient’s behaviors It is useful for the healing process, however studies suggest wound healing relies on vocal activity
Complete voice rest ( CVR)
Used to facilitate greater oral movements to improve oral resonance, reduce extrinsic laryngeal muscle tension, and reduce vocal strain
Chewing
What is the time commitment for Lee Silverman Voice Therapy?
4 times a week for 4 weeks for a 1 hour session
Clinicians use this technique to help patients reduce stress via relaxation exercises
Relaxation
Certification is required Goal: increase loudness by increasing effort and coordination during speech production. Relies on memory, learning and reliance on self- cuing and self- regulating Intensive protocol: 4 times a week for 4 weeks for a 1 hour session Used primarily in patients with Parkinson’s disease
Lee Silverman Voice Therapy
Clinicians realize that the support for voice production is sub glottal pressure. This technique teaches patients how to coordinate the inspiratory and expiratory phases of voice production, optimizing lung volumes for speech
Respiration training
When do you terminate therapy?
- Resolution of the vocal pathology
- Patient satisfaction with voice outcome
- Reimbursement issues
Clinicians encourage patients to open their mouth to reduce dampening of sound production and increase oral resonance
Open mouth approach
The best research design for defining the effectiveness of a treatment is
Large randomized control trials
Vocal habits due to emotional, occupational, or social stresses. Serious cases, should be referred for a psychiatric evaluation. Voice pathologist can help the patient remediate the emotional disturbances associated with the onset or maintenance of the condition.
Psychogenic voice therapy
Clinicians advocate a good posture.chin position, head turning - unilateral tvf Paralysis by turning head to the affected side to aid in vocal fold addiction
Head positioning
Clinicians use a source of noise to induce the Lombard effect, which is known to elevate vocal loudness when noise is introduced to the patient via headphones. Voice clarity may be the result.
Masking
Uses multiple behavioral therapy orientations to address patient’s care
Eclectic therapy
The words used as stimuli run continuously together without changes in stress or prosody. The chant uses elevated pitches, sustained vowels, no syllable stress, and an elimination of hard glottal attacks. The chant is then modified to progress into conversational speech
Chant talk
Goal: eliminate any behaviors that cause trauma to the structural health and function of the vocal folds Focuses on patient education Used with another form of tx
Vocal hygiene
First session: collect patient case history data and educate patient about voice care Second session: introduce resonant voice basic training gesture (RV BTG)- simple sounds, words, phrases, chant, and regular conversation
Lessac-Madsen Resonant Voice Therapy protocol
Used to help patients with hyper or hypo functional voice disorders Developed by Joseph Stemple
Vocal Function exercises
Voice therapy for school aged children with voice disorders (4)
- Largely focused on eliminating vocal behaviors that are not conducive to vocal health (do and do not)
- Rarely successful
- Combination of hygienic and physiologic models of voice therapy in order to address rehabilitation
- Train child if make sounds more therapeutically
Clinicians use this technique to help patients generate a voice source that is optimal with regard to resonance. The direction to the patient is to “move” the voice from the back if the throat to the front of the mouth while feeling vibrations in the nasal cavity. Optimal coupling of the supra glottal and glottal cavities is necessary for best possible voice production
Focus
Direct exercises are used to activate the laryngeal muscle and work other subsystems, such as respiratory and sub glottal systems
Physiologic Voice Therapy
Feedback biological information to gain control of bodily processes that normally cannot be controlled voluntarily Ex. Electromyography Plethysmography
Biofeedback techniques
Used to help adolescent and adult voice patients with hypo and hyper functional voice disorders Target: for the patient to use the least amount of respiratory effort and impact stress on the vocal folds 30 to 45 minute sessions once or twice a week for 4 to 8 weeks
Lessac-Madsen Resonant Voice Therapy
Clinicians use this analysis to help the patient identify the most stressful or anxiety provoking events, comparing situations that create a good voice or a worse voice. Basically, a deconditioning approach is used to help the patient learn relaxation strategies to reduce the stressful or anxious response
Hierarchy analysis
Largely focused on eliminating vocal behaviors that are not conducive to vocal health (do and do not) Rarely successful Combination of hygienic and physiologic models of voice therapy in order to address rehabilitation Train child if make sounds more therapeutically
Voice therapy for school aged children with voice disorders
Who is the primary population Lee Silverman Voice Therapy is used with?
Patients with Parkinson’s Disease
Voice therapy techniques should be based on what?
Empirical evidence for their use and effectiveness
Clinicians strive to reduce this in cases of hyper functional voice disorders. It can be used as a relaxing technique apparently because the vocal folds are vibrating in a more lax state when a low fundamental frequency is produced
Glottal fry
Clinicians use this technique for patients who are unable to produce any voice often due to excessive vocal strain. Vegetative tasks or others can be used to help facilitate any sound production
redirected phonation
Clinicians help the patient identify the behaviors that are causing harmful effects on laryngeal structure or function
Elimination of abuses (phono trauma)
Clinician provides a recorded sample of the patient’s voice for them to judge correct vs. incorrect production
Auditory feedback
What is the goal of Lee Silverman Voice Therapy?
Increase loudness by incresasing effort and coordination during speech production.
Do you need to be certified to officially use Lee Silverman Voice Therapy?
Yes
Clinicians use a modified approach to Aronson’s technique of circumlaryngeal therapy whereby the larynx is gently massaged to reduce the extrinsic laryngeal muscle tension and a lower laryngeal position
Laryngeal massage
- Vocal warm up
- Pitch glides
- Prolonged phonation of /o/ at selected pitches
Vocal function exercises protocol
3 types of interventions
- Behavioral
- Medical
- Surgical
Clinicians use pitch inflections for patients with monotone voice to help activate the cricothyroid muscle
Pitch inflections
Psychogenic voice therapy (3)
- Vocal habits due to emotional, occupational, or social stresses.
- Serious cases, should be referred for a psychiatric evaluation.
- Voice pathologist can help the patient remediate the emotional disturbances associated with the onset or maintenance of the condition.
Clinicians work to minimize extreme cases of hyper function by posturing the tongue in the position for vowel production of /i/. The high tongue position helps to reduce pharyngeal squeezing and is often used in cases of ventricular hyper function/phonation.
Tongue protrusion /i/
Aim: to retain psychiatric symptoms without needing to use this pathology as a coping syndrome
Paradoxical vocal fold dysfunction: psychotherapy approach
Clinicians use this technique to aid patients in identifying incorrect and correct voice productions through visuals
Visual feedback
What is the goal of voice therapy? (4)
- Restore best voice possible
- Focus on functional outcomes
- Reeducate patient on how to use their voice effectively and efficiently
- Eliminate the reformation of the voice disorder/pathology
Clinicians use voice production on inspiration rather than expiration to help modify ventricular phonation for those who are unable to resist voice change when using expiration
Inhalation phonation
Clinician responsibility (6)
- Knowledge and skill of normal and disordered voice production
- Knowledge and skill of therapeutic process
- Compassion, understanding, and empathy
- Superb listening skills
- Counseling skills
- The ability to inspire action for change
Lessac-Madsen Resonant Voice Therapy- Who?
- Used to help adolescent and adult voice patients with hypo and hyper functional voice disorders
What are the five fundamental concepts that the LSVT program is based on
- Thinking loud
- High speed effort
- Intensive treatment
- Recalibrating loudness level
- Quantifying improvements
Vocal function exercises Lessac-Madsen Resonant Voice Therapy Lee Silverman Voice Therapy Inspiratory and expiratory muscle strength training
Examples of physiologic voice therapies
Clinician use physical pressure on the thyroid cartilage to help reduce extrinsic muscle contraction that is minimizing laryngeal movement
Digital manipulation
Clinician helps a patient with consequences of a voice disorder, helping the patient explore the many intrinsic or extrinsic factors that relate to the condition and/or referring the patient for help with psychological issues when those issues go beyond the scope if practice for the voice pathologist
Counseling
Clinicians use words predominated by nasals and glides as therapy stimuli for those with hyper functional voice production as it relaxes the articulators and optimizes nasal resonance.
Nasal /glide stimulation
The purpose is to improve vocal fold adduction, vocal registration, and epilarynx tube narrowing in order it achieve the best acoustic power transfer from the glottis to the lips Lip trills, bilabial fricatives, humming, and phonation into tubes or straws
Semi occluded vocal tract
Clinician educates the patient about how vocal loudness impacts vocal fold vibration and modifies vocal loudness based on the physical condition of the vocal folds.
Change of loudness
How does a voice therapy session begin? (7)
- Describe normal anatomy and physiology,
- etiologic factors,
- correlate etiology and vocal symptoms,
- impact on vocal function
- Measure motivation for therapy
- Discuss a timeline
- Home practice materials
Who would you use Chant talk with?
Clinician uses this technique with hyper functional voice disorders.
Focus (3)
- Clinicians use this technique to help patients generate a voice source that is optimal with regard to resonance.
- The direction to the patient is to “move” the voice from the back if the throat to the front of the mouth while feeling vibrations in the nasal cavity.
- Optimal coupling of the supra glottal and glottal cavities is necessary for best possible voice production
Counseling
Clinician helps a patient with consequences of a voice disorder, helping the patient explore the many intrinsic or extrinsic factors that relate to the condition and/or referring the patient for help with psychological issues when those issues go beyond the scope of practice for the voice pathologist
Open mouth approach
Clinicians encourage patients to open their mouth to reduce dampening of sound production and increase oral resonance
Clinicians use this technique in cases of hyper functional voice disorders by lowering the position of the larynx, widening the pharynx, moving the tongue forward, and reducing extrinsic laryngeal muscle tension
Yawn-Sigh
Based on the notion that strength of skeletal muscles, such as limb muscles, occurs fairly rapidly due to neural mechanisms and eventual muscle hyper trophy as training processes Technique: use a pressure threshold device to blow forcefully through Patients: pediatrics and adults with hypo functional, hyper function, and neurogenic populations
Expiratory muscle strength training
Clinicians most clearly understand that there is no such thing as the concept of “optimal pitch.” however, slight alterations in vocal pitch may be necessary to ensure that the patient is not straining the vocal folds behind their normal anatomic range
Establishing a new pitch
Elimination of excessive voice use, using the voice only when absolutely necessary and in a therapeutic manner Duration should be patient specific
Modified voice rest (MVR)
What is the voice clinician’s role in psychogenic voice disorders?
Discern whether the voice symptoms are due to structural, physiologic, neurophysiologic reasons, and if not, work toward helping the patient remediate the emotional disturbances associated with the onset or maintenance of the condition.
Adductor spasmodic dysphonia treatment options (5)
- Surgical
- Chemodenervation
- Alternative
- Behavioral
- Combined modality approaches
Abductor spasmodic dysphonia treatment
- Botulinum toxin (Botox)
- Inject in posterior cricoarytentoid muscle
Examples of physiologic voice therapies (4)
- Vocal function exercises
- Lessac-Madsen Resonant Voice Therapy
- Lee Silverman Voice Therapy
- Inspiratory and expiratory muscle strength training
Confidential voice- who?
Hyper functional voice disorders
Voice therapy techniques should not be based on what?
Their popularity or promotion
Factors contributing to a successful therapy outcome: (6)
- 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
