Vocal Rehabilitation physiologic approaches, total laryngectomy/alaryngeal means of communication, generalization/maintenance of voice therapy, booster

LARYNGEAL MASSAGE

Muscle tension dysphonia, globus sensation, vocal cord dysfunction, any tightness (Larynx, Hyoid Bone, Sternocleidomastoids, Thyro-Hyoid Space), Shouldn't be talking at all, be relaxed but also breathing

Proper Respiration

Teach abdominal breathing; Helps to reduce tension near the larynx and neck

Proper Respiration May be contrasted with the following breathing methods

Thoracis breathing, Clavicular breathing

Thoracis breathing

chest rises

Clavicular breathing

shoulders rise

EFFICIENT PHONATION THROUGH SYMPTOMATIC APPROACH EXAMPLES

Establish an appropriate pitch, Establish easy onset of phonation, Establish appropriate vocal intensity, creative technique

Establish an appropriate pitch

May use VisiPtich or other software applications for visual feedback; Hum and alter pitch either up or down to reach a healthier fundamental

Frequency

Establish easy onset of phonation

Initiate phonation without hard glottal attacks

Establish appropriate vocal intensity

Set lower level of vocal intensity for the client

EXAMPLE OF ESTABLISHING A VOICE USING A "CREATIVE" TECHNIQUE for Functional aphonia or

Severe dysphonia

Begin with a cough; Prolong cough into normal vowel Production; Production of all vowels; Monosyllabic words; Any word; Simple phrases; Oral reading; Simple conversation; Conversation about anything with Anyone; Generalization to everyday conversation

Physiologic Voice Therapy

Based on expanded knowledge of vocal function using more

objective voice evaluation and measurement techniques

Physiologic Voice Therapy Goal

to improve coordination of voice subsystems using; Respiratory support, Improved phonatory strength/efficiency, Supraglottic modification of laryngeal tone via resonance

Commonly used Physiologic Voice Therapy exercises

Strength based/physiologic, Function/coordination based

Strength based/physiologic

Vocal Function Exercises, PhORTE, general adductory exercises

Function/coordination based

Resonant Voice Therapy and Flow Phonation

Do people who talk too much need voice exercises

yes if not acute conditions, extended voice rest (>3-5 days) may be harmful, "low impact" voice therapy exercises can improve tissue

inflammation faster, "physical therapy" for vocal folds is easy for patients to understand

TYPES OF PHYSIOLOGIC APPROACHES TO VOICE THERAPY

Lessac-Madsen Resonant Voice Therapy, Vocal Function Exercises, Lee Silverman Voice Treatment, Semi-Occluded Vocal Tract Exercises

LESSAC-MADSEN RESONANT VOICE THERAPY (LMRVT)

Voice production involving forward tone focus with easy phonation (to reduce stress and reduce laryngeal injury),Instructed to feel voice mid-face by focusing a single perceptual target, This SINGULAR focus has been shown to affect multiple systems, Goal to attain maximum vocal output of least amount of

effort/shearing forces between vocal folds, Therapy takes place 1-2 x/week for 4-8 weeks

LMRVT PROTOCOL Rationale

Case history data and voice care education, Introduce the Resonant Voice Basic Training Gesture (RV BTG), Training on words/phrases using a resonant voice, Variable practice of resonant voice for better generalization, Emphasize sensory processing/variable practice

Introduce the Resonant Voice Basic Training Gesture (RV BTG); stretches

Hum focused in the facial bones, Hum with varying pitch

Training on words and phrases using a resonant voice

/m/ words, phrases, and sentences

Variable practice of resonant voice for better generalization: Conversation in quiet setting, noisy setting, controversial conversation, emotional conversation

LMRVT Protocol stretches

Shoulders (rolls, elbows to back, arms out front), Neck (chin tuck, head up jaw out, ear to shoulder, etc.), Jaw (massage masseters pull down), Lips (trills), Tongue (trill, stretch with open mouth), Pharynx (yawn)

Vocal Function Exercises Rationale

Set of systematic exercises designed to strengthen/balance voice production subsystems, Softly engaged voice with least amount of effort/without pitch breaks, wavering, breathiness in voice quality; Use appropriate posture, diaphragmatic breathing, tone placement, onset, Clinical trials indicate improved phonation volumes, phonation times, glottal efficiency, frequency range

Vocal Function Exercises

Warm-Up, Stretching, Contracting, Adductory Power

Warm-Up: Sustain nasal /i/ vowel on F above middle C for females & boys or F below middle C for men; creates more forward vocal focus (but we don't tell them to make a nasal phoneme)

Stretching

Glide from patient's lowest note to their highest note using the word "knoll"; tongue/lip trill; whoop, goal is to not have voice breaks but if it happens we still continue

Contracting

Glide from the patient's highest note to their lowest note using the word "knoll"; tongue/lip trill; boom

Adductory Power

Sustain the musical notes (C-D-E-F-G) for as long as possible using the sound "ol" (as in"knoll" minus the "kn")

Vocal Function Exercises General Considerations

Soft voice, but still "engaged", Avoid glottal attacks at onset but avoid an aspirate breathy attack, Training in abdominal breathing can be given, Use of an outside aid for pitch matching (keyboard app, pitch pipe, etc.), Estimated time of completion is 6 weeks with a tapering of home practice

Lee Silverman Voice Treatment (LSVT)

Evidence-based treatment program effective for Parkinson's Disease; vocal loudness is a trigger for stimulating increased respiratory/laryngeal effort to improve muscle coordination during voice/speech production; Intensive treatment, 4 days/week for 4 weeks (16, 1 hour sessions); Hierarchical tasks; increased vocal loudness by 8 dB, positive effect on swallowing, altered facial expressions, maintenance required after 1 year

LSVT 5 fundamental concepts

Think loud; Increased vocal effort; Intensive treatment; Recalibrating loudness level; Quantifying improvements

Semi-Occluded Tract Exercises (SOVT)

trains relaxed throat posture for voice; Optimize airflow; Facilitate better coordination between respiratory/phonatory subsystems; Used with hyperfunctional voice disorder; can be "warm up"/"cool down" exercises for high-demand voice users or singers

SOVT Goals

Improve vocal efficiency; Improve vocal loudness with minimal stress to vocal folds; Improve vocal fold adduction (reduce collisional force); Decrease vocal tract constriction (improve forward oral resonance)

SOVT types

Straw Phonation (Pitch glides, vowels) Fricatives & Trills (Voice and hold, Lip trills, Tongue trills), Nasals & Vowels (Voice and hold), Generalizing to Conversation (Vowels, Phrases, Read aloud, Conversation)

Straw Phonation; Vowels

Produce "ooh" in a comfortable pitch; feel vibration of the lips against the straw and on your fingertips

Straw Phonation; Pitch Glides

Glide up and down in pitch using "ooh"; feel vibration of the lips against the straw and on your fingertips

Fricatives & Trills; Voice and hold; /v/, /ð/, or /z/

feel vibrations on your lips, tongue, or teeth

Fricatives & Trills; Lip trills

at a comfortable pitch, then glide up and down on the pitch

Fricatives & Trills; Tongue trills

on a comfortable pitch, then glide up and down on the pitch

Nasals & Vowels; Voice and hold; /n/, /ɳ/ or /m/

feel vibration at the front of nose, mouth, and teeth; Glide up and down on this sound

Nasals & Vowels; Voice and hold "ooh" or "eee"; feel the vibrations near the lips or the roof of

the mouth; glide up and down on this sound

Generalizing to Conversation; Vowels

voice and hold a vowel sound (i.e. "ooooooh"), Phrases: start with a /wh/ word and say a phrase (i.e. "Whoooo are Theeeeeey"), Read aloud: maintain forward resonance and ease of voice, Conversation: build to unstructured conversation

Expiratory Muscle Strength Training (EMST)

Overloads the expiratory muscles - form of resistance training; Gradually increases expiratory pressure up to 150 cmH2O; Used with hypofunctional, hyperfunctional, and neurogenic voice disorders; Used with presbyphonia

(EMST) Goals

Increase the force-generating capacity of expiratory muscles, Some reports of improved communication quality of life, Some report improved vocal loudness, vocal quality, and voice-related quality of life

EMST; What is happening?

Increase muscle activity of the suprahyoid muscles; Causes the vocal fold adductor; muscles to co-contract with high expiratory pressure; Strengthens the geniohyoid Muscles

Other Voice Treatment Options

Gender affirming voice therapy, PhoRTE, Conversation Training Therapy, Vocal yoga, Eclectic, Management of Paradoxical Vocal Fold Motion

Gender affirming voice therapy

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Conversation Training Therapy

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Vocal yoga

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Eclectic

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Management of Paradoxical Vocal Fold Motion

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TOTAL LARYNGECTOMY

Removal of entire larynx, Trachea is redirected to form an opening in front of the next, called a stoma

Total Laryngectomy when

The laryngeal carcinoma is not amenable to conservation surgical/non-surgical management; also performed if first-choice treatment of radiation failed; If larynx becomes nonfunctional following cancer treatment

various alaryngeal means of communication

Artificial Larynx/Electrolarynx, Esophageal Speech, Tracheosophageal Puncture (TEP)

Artificial Larynx/Electrolarynx

Battery operated machine that produces sound for the patient; About the size of a small razor; Holds against the neck, or fit a small tube into the corner of their

mouth; when they press the button, it makes sound, then the articulators for words

Artificial Larynx/Electrolarynx Used in individuals

who are not able to have a voice prosthesis or

are waiting for the voice prosthesis to be inserted

Esophageal Speech

Air injected into esophagus and upper musculature of esophagus; is used as vibrating site for alaryngeal phonation; Patient moves air into upper esophagus, then reverses process; air is forced out of esophagus under pressure; sound is resonated/articulated into human speech by articulators

Tracheoesophageal Puncture (TEP)

Surgically produced tracheoesophageal fistula links trachea/esophagus; Primary/secondary procedure; Silicone prosthesis inserted into TEP; Prosthesis is one-way valve; Manually occlude stoma/may use an air pressure tracheostoma valve

generalization and maintenance of voice therapy

Trains family/others to support newly acquired vocal behaviors ASAP; Teaches recognizing phonotrauma; teaches charting/counting those behaviors; Teaches to stop client whenever they exhibit phonotrauma; Teaches modeling a more appropriate vocal behavior; Teaches reinforcing/strengthening desirable vocal behaviors

the purpose of booster treatment

Obtain follow-up measures at regular intervals, If the follow-up shows that the client's voice is abnormal or that phonotrauma is on the increase, provide booster treatment