Voice Rx Flashcards
Possible professionals to work with in voice?
ENT, GP, Dietician, Psychologist, gastroeneterologist
What are some PROMS for for Voice goals?
VHI-10 PVHI SVHI RSI CSI
VHI-10: norms
> 11 = disordered voice (Arffa et al 2012)
PVHI: norms
3-12 = not disordered
RSI: norms
> 15 90% chance of reflux (Belafsky et al 2002)
CSI: norms
> 3.23 is considered symptomatic for cough (Shembel et al, 2014)
Outcome measures for Voice goals?
- PROMS
- Perceptual analysis
- Acoustic analysis
- Endoscopy
What is Fo usually analysed from?
conversational speech
Norms for Fo?
Women: 199 mean,
Men 115 mean
(Leung et al 2020)
Norms for MPT?
Women 11-26secs
Men 11-28secs
(Goy et al 2013)
<10 is concerning according to Alisa
What is HNR analysed from?
MPT/prolonged vowel
HNR norms?
> 25 correlates with perceptually clear voice (Warhurst et al 2012)
How can we assist clients to deal with disordered voice?
Provide information Make suggestions for changing behaviour Reorganise disordered voice Compensate for the disordered voice Consider client's and others perception of their voice Consider related issues
Types of voice therapy?
Direct and Indirect
Direct therapy is….
Teaching client to use voice differently
Indirect therapy is…
making suggestions and providing advice and advocating re: voice hygiene, amplification, strategies etc
Considerations for voice management plans
- direct vs indirect
- further referrals required
- information client needs
- rx options and recovery prospects
- child vs adult approaches
- culture, ethnicity, gender
BS and F voice goals: nodules
Xs nodules will be reduced, demonstrated by an endoscopy conducted by the ENT by the end of the 8 week block of therapy
BS and F voice goals: VF closure
X will demonstrate improved VF closure as demonstrated by an increase MPT of … in the clinic after a 6 week block of therapy
Activity voice goal: auditory perceptual voice rating
X will demonstrate improvement in auditory-perceptual voice rating as measured by CAPE-V scores <10 for overall severity ( and other specifics) at the end of an 8 week block of therapy
Activity voice goals: improved vocal clarity
X will demonstrate improved vocal clarity as evidenced by an HNR score of >25dB or above on MPT in the clinic at the end of 8 week block of therapy
Participation Voice Goal: PVU
X will be able to undertake fulltime telephonist duties , with no deterioration in voice quality or stamina, measured by VHI-10 score of <11 at the end of 8 week therapy block.
Poor vocal hygiene examples
shouting/screaming, talking loudly over noise, coughing/throat clearing, poor hydration reduce caffeine, smoking, alcohol, drugs manage reflux check meds sleep and good diet
Better alternative for throat clearing
yawn, sip water, forceful swallow, silect cough
Better alternative for yelling/cheering
gestures, whistle, amplification, ensuring in same room as person
Which organic voice disorders require surgery?
cysts
papillomas
carcinomas
Which organic voice disorders should be first treated with voice therapy?
nodules
polyps
SLP role pre voice surgery
provide info and support for procedure
teach voice technique for post op
support ENT recs and client’s best interests
SLP role after voice surgery
- assist client to implement pliability exercises to assist - healing and follow post op recs
- track recovery
- make sure voice functioning optimally (minimise any compensatory behaviours)
- watch/listen for scarring and refer to ENT if needed
Voice use time line after surgery
- follow ENT guidelines
- no speaking for 3-10 days for epithelium healing
- 3 weeks for swelling to reduce
- increase in voice use of 25-33% per week (depending on voice use e.g. teacher needs to be less)
- restructuring of VFs can take up to a month
- complete healing of VF depending on degree of invasion up to 6mo or 12mo for cordotomy3-6 weeks for healing of deeper layers
example Rx for respiration subsystem
marking paragraphs with phrase markers for when to breathe
Example Rx for loudness
refer for hearing, raise awareness and use soundometer. LSVT.
4 steps for psychogenic voice management
- medical evaluation to exclude pathology
- Diagnostic voice evaluation ( case hx etc)
- manipulation of voice
- probing cause of disorder (usually psychological - refer)
Another term for psychogenic aphonia
functional aphonia/dysphonia
What is psychogenic dysphonia?
psychological trauma causes dissociation and loss of conscious access to vocal function
Rx for psychogenic dysphonia
- reassurance
- blame vocal mechanism e.g. for some reason your VFs are not closing all the way
- produce voice using emotional vocalisation/airway protection (cough, laugh, mmhhhmm)
- extend into speech similar to RVT with no time given for client to think (mm, me, more, more money)
How soon can you expect improvement in psychogenic dyphonia with Rx?
Often dramatic changes within the first session
What is puberphonia?
when voice doesn’t adapt to change in size at puberty (usually strained and tight and hoarse). may have gender role, maturity issues.
Rx for puberphonia?
- Lx examination to deternime normal mechanism
- explain problem
- direct vocal manipulation: produce hard glottal attack to break voice into lower register. Get client to repeat and shape into words and convo and extinguish hard glottal attack
- manual lx reposturing: resisting elevation to lower pitch, fade cues
- consider identity and voice exploration
List some voice rx for Muscle tension dysphonia
Yawn sigh trill with sirening SOVTes VFE RVT OPT
Explain process of yawn-sigh
yawn then shape into a sigh (without breathy onset h) Appreciate sensation. then pair with vowels and shape into words)
What does yawn-sigh do?
reduces medial compression
lowers lx
increase perceptual awareness
what does trill with sirening do?
instructions?
and what is it good for?
reduce medial compression
lengthen and shorted VF (increases range)
increases perceptual awareness
glide up and down then siren
post surgery
What does straw phonation do?
reduce medial compression
increase closure of VP port
increase perceptual awareness
which voice rx increases closure of VP port (improves hypernasality?
straw phonation
what does RVT do?
reduces medial compression
raises larynx
increases perceptual awareness
What does OPT do
reduces medial compression lowers lx? assists VF approximation lengthens VFs increases muscular control reduces vocal mass increase perceptual awareness
What do Stemples Vocal Function Exercises (VFE) do?
increase loudness
assists VF approximation
lengthen and shorten vf (increase range)
increase perceptual awareness
Examples of SOVTes?
nasals lip and tongue trills straw phonation spooky ghost fricatives /v/, /z/, /zhhh/, voiced th
What is RVT?
voice production involving oral vibratory sensations, usually on anterior alveolar ridge or higher
EBP for RVT
consistent results in improving voice quality and production (Yiu et a 2017)
RVT process:
BTG and Stage 1:
Basic Training gesture: good posture, model breath and sigh with voice ‘molm’ drawing attention to vibrations in body, focus them to front of face and feel connection between abs and lips
- MOLM: with sustained pitch, varied rate, varied intensity and rate, using speech intonation with varied pitch, loudness and rate, chant /m/ heavy phrases on musical note then with over inflection
RVT process: Stage 2 & 3
- VOICED/VOICELESS:
- non-linguisitic phrases e.g. mamapapamamapapa with varied rate, varied intensity and rate, speech intonation. - chant voiced voiceless phrases e.g. my movie made Tim and Tom sad, and repeat with exaggerated intonation - ANY PHRASE: repeat any 5-7 syllable phrase with
- chanting
- overinflection
RVT process: stage 4 & 5
- PARAGRAPH with
- phrasemarkers
- exaggerated forward focus then normal
- no phrase markers - CLINIC CONVERSATION with no distractions
(avoid glottal attack)
RVT process: stage 6 & 7
- NATURALISTIC CONVERSATION
7. EMOTINALLY ENGAGING TOPICS IN CONVERSATION
OPT process
- talk about clarity and effortlessness
- model and repeat aiming for clear and effortless, asking how it sounds and feels
- breathe in and breathe out silently through mouth
- repeat with added mmm (quiet with easy onset)
- extend into words and phrases
- smile if noisy
Rx for Parkinson’s related voice issues
LSVT
What is LSVT?
intensive rx that emphasises loud voice to improve respiratory support, articulation, facial expression and animation
How often should LSVT sessions be
4 days per week for 4 weeks plus home practice
Recommended voice treatment for reflux?
RVT
Rx for VF paresis/paralysis
Surgery and VFE
Treat for hyperfunction with RVT if required after
Rx for Hypoadduction
EMST
use of reflexive acts and increased energy to gain closure
Rx for hyperadduction/MTD
RVT/OPT
posture adjustment
address underlying causes e.g. stress, reflux
Rx for ataxic dysarthria
Reduce rate to provide more time to control and organise muscles
RX for spasmodic dysphonia
RVT and Botox
Which type of spasmodic dysphonia responds best to Botox?
adductor
Rx for essential tremor
RVT/OPT/Yawnsigh
Botox (mixed success)
rx for paradoxical VF movement
- neuromodulators
- anti reflux strategies and info
- relaxation exercises
- inhaling through nose with lips closed
- RVT for MTD
- quick sniff through nose during attack
rx for chronic refractory cough
cough suppression techniques and education
Discharge criteria for voice
- symptoms gone- voice is meeting needs
- cause is addressed
- increased awareness of causal factors
- Clinician judgement
- Client choice
Considerations for voice therapy for children
- age appropriate reading passages
- use different terminology e.g. monster vs hero voice, buzzy bee sound etc
- rewards - extrinsic rewards use operant conditioning like Lidcombe program
Considerations for PVU
- time of work workplace pressure - higher level of anxiety - reputation - identity - work cover requirements
Rx for transgender M->F
- elevate fundamental frequency (include coughing etc)
- increase inflectional patterns, articulatory precision, rate
- lengthen pauses
Some side effects of radiotherapy
Can get worse over time xerostomia oedema muscle atrophy (so many)
Some side effects of chemo
hair loss taste issues reduced appetite nausea reduced energy mucosa damage
a regression at 2-3 months post surgery could indicate what?
scarring
Rx for loud children with roughness, loss of voice
- discussion about voices in general to improve awareness
- if I can’t see you I can’t hear you rule
- Yell Well program
- use of gestures for getting attention
- instrument for cheering at sport
