MS Final (management of respiration & phonation)

during speech, the respiratory system is the source of ____

aerodynamic energy

speaking involves

production of steady utterances → produced with relatively stable alveolar/subglottal air pressure levels

true or false: if respiratory performance is severely impaired, adequate speech may be impossible

true

other speech systems are ____ by patterns of respiratory support for speech

strongly influenced

subglottal air pressure is generated by (2)

the driving forces of the respiratory system

the resistance to airflow imposed by the glottal and supraglottal structures

compression results from what two forces generated by the respiratory system?

muscular activity and elastic recoil of respiratory structures

forces of elastic recoil vary depending on ____

lung volume level (larger volume = larger force)

how much cm H2O is generated by relaxation forces alone at 70% lung volume level in the upright position?

15cm

at 36% of lung volume level, the relaxation forces generate _____ cm H2O

0

(establishing respiratory support) speaker has estimated levels of alveolar air pressure of _____ of water or less on speech or speech like tasks

5cm

(establishing respiratory support) speaker is unable to sustain consistent air pressure for ____

5 seconds

(establishing respiratory support) Speaker is unable to generate adequate alveolar ir pressure to

support phonation

(establishing respiratory support) speaker has such limited respiratory support or control for speech that a ________ speech pattern is used during connected speech

one-word-at-a-time

establishing respiratory support (3)

production of consistent alveolar/subglottal pressure

postural adjustment/prostheses

inspiratory checking

management for production of a consistent subglottal pressure

1. EMST (ex. has been shown to improve resp function in COPD, MS, PD_

2. blow bottle training

postural adjustment/prostheses options

• often unable to maintain adequate air pressure in a seated positions

• supine position may assist in expiration in flaccid

• in spastic positions that reduced excessive muscle tone may be appropriate

• for hypokinetic, positions that allow expansion of the respiratory system

• respiratory binder sometimes used for SCI (very dangerour for people with inspiratory weakness so rebecca doesn’t like)

• expiratory board/paddle (lean into board as you prepare to phonate, increasing expiratory forces)

inspiratory checking is a compensatory strategy for SwD who ____

release excessive airflow through the larynx when they speak

what do inefficient airway valves do?

send the respiratory system into overdrive (forcing excessive air from the lungs through vocal tract)

inspiratory checking

• instruct to control flow of air through the larynx

• inspiratory muscles used to counter elastic recoil forces

• results in gradual release of air supply to support speech

some speakers initiate phonation at ____

inappropriate lung volume levels (too high or too low)

some speakers initiate speech without _____

taking a preparatory inhalation

some speakers initiate breath groups at _____

inconsistent lung volume levels

some speakers consistently produce utterances that are____

too loud or too quiet

some speakers do not terminate a breath group _____

at an appropriate lung volume level (or continue to speak until speaking excessively low level)

what do you need to identify a functional lung volume range?

access to spirometry

typical speakers generally inhale to approximately what percentage of lung volume level?

60%

speakers with CP inhale to a _____ where the relaxation recoil will assist in generating needed air pressure in vocal tract

high lung volume

what has to happen before an optimal inspiratory lung volume level for speech can be determined?

must ax the ability of the speaker to check the recoil air pressure generated at high lung volume levels

once previous respiratory goals have been accomplished you can target

respiratory flexibility

increased flexibility with which the respiratory system is controlled during speech leads to

increased naturalness of overall speech pattern

(increasing respiratory flexibility) Adjusting lung volume levels

• teach general rules that govern respiratory performance during speech

• SwD reads paragraphs in which the resp patterns have been marked

• conversation scripts for two speakers prepared with resp patterns marked

• speaker reads aloud or speaks conversationally without aid of pattern markings

(increasing respiratory flexibility) Maximizing speech naturalness

• natural stress patterning

• flexibility may also be added by teaching pause without inhalation

• pauses re typically used to add emphasis/increase naturalness

hypoadduction impairment results from

LMN laryngeal paresis or paralysis as well as PD, PSP, Shy-Drager syndrome, and some TBIs

hyperadduction impairment results from

PSP, spastic CP, HD, adductor laryngeal dystonia, and some brain injuries

short term phonatory instability

fluctuations in intensity and frequency on a cycle by cycle basis, is perceived as a problem in voice quality, is present in most persons with neuro voice disorders

long term phonatory instability

fluctuations in vocal frequency and intensity occurring in intervals greater than one cycle

3 kinds of long term phonatory instability

1. very slow fluctuations occur less than 2 times/sec

2. tremor refers to fluctuations that can be observed 3-10 times/sec

3. flutter refers to very fast (7-10 times/sec) changes in frequency and intensity

mixed phonatory impairments may occur in

MS, ataxic dysarthria, sometimes PSP and Shy-Drager

establishing voluntary phonation for speakers with severe hypoadduction

1. evaluate reflexive phonation: evaluate nonspeech reflexive patterns that might be associated with phonation (laugh, cough, grunt, sigh) → take note of positioning

2. develop voluntary phonation: attempt a reflexive behaviour, position ofr optimal generation of subglottal air pressure

what is the goal of establishing voluntary phonation?

more forceful VF adduction → may use traditional pulling-pushing exercises

increasing loudness for persons with hypoadduction of VFs

• train to generate larger subglottal AP (blow bottle, EMST)

• initiate phonation at appropriate lung volume levels

• initiate phonation at appropriate times in resp cycle

• increase medial compression (effortful closure techniques like pushing, lifting, grunting, controlled coughing, head turn or digital pressure to thyroid)

• LSVT

phonatory coordination impairments

involve the coordination of the phonatory system and articulation in order to achieve voiced-voiceless distinctions or to achieve aspiration-nonaspiration distinctions

lombard inducing devices

• people tend to speak loudly in the presence of background noise

• lombard devices produce noise to an individual with hypophonia to trigger lombard response

reducing hyperadduction of the VFS

• decreasing effort can be accomplished through direct instruction or through feedback (like a sound-level measuring device or a system to monitor oral air pressure during speech)

• relaxation/voice therapy

• botox injection into throarytenoid muscle

improving laryngeal coordination: respiratory-laryngeal timing

prompt initiation of phonation at beginning of exhalation phase of respiration

• use resp biofeedback in training

• initiate phonation by using an effortful closure technique

improving laryngeal coordination: articulatory distortions

SwD have difficulty producing perceptually different voiced-voiceless cognate pairs or producing inital /h/

• can have speakers exaggerate other aspects of the voiced-voiceless distinction

compensatory approaches for hypophonia

• voice amplifiers (Nady 351VR most preferred by clients in study)