Voice Final: Voice Facilitating Approaches

Auditory feedback

*should be combined with other approaches

Benefits: most voice patients

Parameters affected: loudness & quality

Procedural aspects: real-time amplification, metronome pacing, loop playback

Evaluation of approach: corrects disorder by listening to one’s voice

Change of loudness

*only addressed after full audiological exams

Benefits: Ppl with too loud/too soft voice, motor speech disorders

Parameters affected: pitch, loudness, quality

Procedural aspects: increase self awareness

• Decrease in loudness

  • provide contrasting levels of loudness & auditory feedback, practice using quiet voice

• Increase in loudness

  • change pitch level and fundamental frequency, respiration training, masking

Evaluation of approach: having immediate access to biofeedback

Chant-Talk

*loud monotone; words run continuously together without stress or a change in prosody for the individual word segments

Benefits: hyperfunctional voice

Parameters affected: loudness, quality

Procedural aspects:

1. Explain approach to patient as a way to reduce talking effort

2. Urge patient to imitate same chant voicing

3. Patient should read aloud, alternating regular voice and chant voice

4. Record patient’s oral reading

5. Once patient can produce chant-talk with ease, they should try to reduce the chant quality

Evaluation of approach: reduced vocal fatigue in teachers

Chewing

*voicing during exaggerated chewing

Benefits: vocal hyperfunction, MTD

Parameters affected: pitch, loudness, quality

Procedural aspects:

1. Increasing awareness regarding the need for greater mouth opening

2. Demonstrating exaggerated chewing through mirror

3. Adding light voice to chewing

4. Asking patient to count and chew

5. Using words and phrases during chewing

6. Diminish the exaggerated chewing to resemble more normal mouth movements

7. Patient just “thinks” the chewing method while talking

Evaluation of approach: effective in reduction and in some cases elimination of vocal nodules

Confidential Voice

*breathy voice with less loudness, as if one doesn’t want to awaken a person sleeping nearby

Benefits: vocal hyperfunction

Parameters affected: loudness, quality

Procedural aspects:

1. Modeling breathy, confidential voice

2. Breathy, light voice uses up more air

3. Temporary use is then explained

Evaluation of approach: Reduced vocal hyperfunction in 39 adults with functional dysphonia

Digital Manipulation

*Finger pressure on the thyroid cartilage

Benefits: puberphonia, UVFP

Parameters affected: pitch, quality

Procedural aspects:

1) Lower pitch (puberphonia)

• Ask patient to prolong a vowel (/a/ or /i/) and apply slight finger pressure on the thyroid cartilage. Pitch level will drop immediately.

• Ask patient to maintain the lower pitch after the fingers are removed

2) Unilateral digital pressure (UVFP)

• Head straight, patient phonates; clinician exerts pressure on the lateral thyroid wall on the side of the VF paralysis

• If the louder voice was not achieved, apply pressure on the opposite side.

• If the louder voice was not achieved, patient turns the head to one side. Apply pressure on the same side.

• If the louder voice was not achieved, apply pressure on the opposite side.

Evaluation of approach: Technique may obviate quest for surgery

Glottal Fry

*Produced in a relaxed manner with very little airflow and very little subglottic air pressure

Benefits: vocal nodules, polyps, cord thickening, functional dysphonia, spasmodic dysphonia, ventricular phonation

Parameters affected: loudness, pitch, quality

Procedural aspects:

1. Modeling glottal fry

2. Produce same tone on inhalation and exhalation

3. Extend glottal fry to sentences and other phonation tasks

Evaluation of approach: works bc little subglottic pressure and very little airflow are required to produce the glottal fry

Hierarchy Analysis

*Listing various situations that ordinarily produce some anxiety for the patient and arrange those situations in a sequential order from the least to the most anxiety provoking

Benefits: vocal nodules, polyps, cord thickening, functional dysphonia

Parameters affected: loudness, pitch, quality

Procedural aspects:

1. Developing a general awareness of the hierarchical behavior

2. Deconditioning the response from the least anxious to the most anxious situations

Evaluation of approach: often helpful for dealing with vocal inconsistencies experienced while talking with different people in various situations

Inhalation Phonation

*Phonation during inhalation; optimally produced with a high /i/

Benefits: functional dysphonia and aphonia

Parameters affected: loudness, pitch

Procedural aspects:

1. Demonstrate inhalation phonation

2. Match the high-pitched inhalation voice with expiration voice

3. Changing the pitch to the regular pitch

4. Move towards the single-word practice

5. Once the patient can produce the exhalation voice without the inhalation prompt, the inhalation practice is no longer needed

Laryngeal Massage

*gentle manipulation and massage of the larynx

Benefits: functional voice disorders

Parameters affected: pitch, quality

Procedural aspects:

1. Apply light pressure with the fingers in a circular motion over the tips of the hyoid bone and the major horns

2. Find the posterior borders of the thyroid cartilage and repeat the procedure

3. With the fingers over the superior borders of the thyroid cartilage, begin to work the larynx gently downward and laterally at times

4. Ask the patient to prolong vowels during these procedures and note changes in quality or pitch. Clearer voice quality and lower pitch indicate relief of tension

Evaluation of approach: Supportive in assessment and management of hyperfunctional voice disorders

Nasal-Glide Stimulation

*Entail little to no obstruction of voiced energy in the nasal and oral cavities; therefore these sounds are very easy to produce

Benefits: function voice disorders, spasmodic dysphonia; dysphonias related to fold thickening, nodules, and polyps

Parameters affected: quality

Procedural aspects:

1. Monosyllabic and polysyllabic nasal consonants: man, moon, many, morning, many, men

2. Introduce an /a/ between each word. “man a man a man” or “wing a wing a wing”

Evaluation of approach: Facilitate easy voice production

Open-Mouth Approach

*Encouraging the patient to develop more oral openess

Benefits: vocal hyperfunction

Parameters affected: loudness, quality

Procedural aspects:

1. Increase self awareness using visual feedback

2. Starting from a single word and continuing to the conversational level

3. Redirecting to communicative phonation practice materials

Evaluation of approach: End point of the vocal resonator is the open oral cavity, which contributes acoustically to the formation of the majority of phonemes

Redirected Phonation

*SLP searches with the patient to find some kind of vegetative phonation

Benefits: some children and adults with voice problems experience difficulty “finding” their voices

Parameters affected: pitch, loudness, quality

Procedural aspects:

1. Encouraging the patients to produce vegetative sounds such as coughing, gurgling, humming, laughing, trilling, um-hum, throat clearing

2. Prolonging the nonverbal voice with an extended vowel

3. Redirecting to communicative phonation practice materials

Evaluation of approach: Clinician searches with the patient to find some kind of voicing, then takes that phonation and redirects it into the speaking voice

Visual Feedback

*Reinforcing treatment with quantitative visual information of the voice

Benefits: Any patient

Parameters affected: pitch, loudness, quality

Procedural aspects: Ranges from simple instrument (i.e. mirror) to more advanced computer-assisted software programs

Evaluation of approach: Promising results

Yawn-Sigh

*One of the most effective therapy techniques for minimizing the pathologic tension in vocal cords

Benefits: vocal hyperfunction

Parameters affected: pitch, loudness, quality

Procedural aspects:

1. Demonstrate yawn

2. Ask the patient to yawn again and then to exhale gently with light phonation

3. Move to the word, sentence, and conversation level

4. Ask the patient to maintain a relaxed phonation simply by imagining the approach

Evaluation of approach: Powerful technique for hyperfunction