Motor Speech Quiz Weeks 7-9

What are the medical interventions to voice problems?

Antibiotics, allergy treatment, anti-reflux diet and medication, mucoytics, steroids.

What are the behavioral interventions to treatment voice problems?

Voice rest and voice therapy

What are the surgical interventions to treating voice problems?

Phonosurgery and augmentation/framework surgery

What are acute voice problems?

URI, Hemorrhage and Mucosal irritation (phonotrauma)

What are chronic voice problems?

Phonotrauma, benign lesions and malignant lesions

Allergy treatment for voice problems include

Antihistamines, nasal steroids and immunotherapy

Medical reflux management for voice problems include

Concern for active role of reflux only and pH probe analysis

Steroid treatment for voice problems include

Systemic and topic/inhaled- minimal indication

Treatment of Glottal Insufficiency

Goal is to eliminate the glottal gap during phonation which can be done by injection augmentation and framework surgery

Medialization Laryngoplasty

To improve glottal closure through solid implants, done through a incision in the neck, pt. is awake but sedated which allows for tuning of the voice and is often used adjunctively with arytenoid adduction.

What is the key to treating voice problems?

Shared decision making between laryngologist, SLP, patient and family members

What does a voice evaluation include?

Laryngeal exam and referral from ENT, case history, perceptual assessment, objective measurement, stimulability, recommendations and prognosis, treatment plan/goals

Referral must include?

ENT (laryngology specialist), diagnosis- vocal fold lesions/tissue, vocal fold motion, vocal fold closure patterns (determined by strobes only), recommendations/plans- behavioral therapy (speech, singing), medications, surgery.

What is need to know about first impressions when taking a case history?

Know your patients background- talk to MD, whats the diagnosis, medications, voice rest, surgery, get information you need to know to take the nest step, learn to listen more than talk, listening without judging, predicting or stereotyping, understanding patient is the expert, be curious of persons needs goals fears and be supportive.

Asking questions during case history

Open ended questions- what is worrying you about your voice, what exactly happens when you have problems, tell me more- avoid serial questions- focus on behavior and feelings- go through a typical day, check if pt. wants to add anything

Eliciting more information

Facilitative responses, reflect back what you are hearing, summarize and asking patient to add anything you may have missed

Case History- What’s the story?

Onset and progression, PMH, vocal schedule and personality, lifestyle and motivation

Onset and progression

How did it start and how has it changed?

When did you first notice your voice problem?

Did it come on suddenly or gradually?

Is your problem getting better, worse or staying the same?

What are your current symptoms?

Have you had a voice problem in the past?

What treatment have you had?

Common symptoms based on patient report include:

\-The sound of the voice-too harsh/hoarse/raspy, voice loss, too high/low, too loud/soft, reduced vocal range

\-The feel of the voice- too effortful, painful/irritated/sore, dry throat, increased mucous

Case History: PMH- Dysphonia

\-Illness: bacterial or viral,

\-Surgery

\- Irritation: internal vs. external

\-Phonotrauma or blunt trauma

\-Neurological disorders

\-\*Congenital conditions

PMH can include?

Neurological-Parkinson’s

Congenital- laryngeal malaysia, webbing, stenosis, airway issues

Case History: Vocal Schedule and Social HX- Dysphonia

\-Work related activities

\-Social activities

\-Home related activities

\-Personal habits

Case History: Lifestyle-Dysphonia

\-Sleep and fatigue levels

\-Diet and exercise

\-Stress and emotional health

Stress and emotional health can have a big impact on the voice

\-General level of well being, smoke, alcohol

\-Are there any significant stressors in your life?

\-Anything causing stress right now that I should know?

Case History: Patient Motivation Ruler Method

On a scale of 1-10 how important is it for you to address your problem?

On a scale of 1-10 how confident are you in your ability to change?

Self efficacy- belief in how we can change

Perceptual Assessment

What their perception is and what your perception and note if there is a discrepancy between the two areas

Perceptual Assessment: Patients Estimation

Quality of Life Survey (VHI)- level of effort

* Physical
* Psychological
* Social
* Economical

Track progression of condition and effectiveness of treatment

Perceptual Analysis: Clinician’s Perception

CAPE-V

Patient motivation

Stimulability- trail therapy

Voice Handicap Index-10 (VHI-10)

Validated and standardized questionnaire= self analysis of quality of life issues as it relates to:

* Functional
* Physical
* Emotional

Objective evaluations include:

Stimulability testing

Stimulability testing includes:

\- Kinesthetic awareness

\-Builds self efficacy

\-Assess readiness

Stimulability testing impressions

\-Summary of the patient diagnosis and symptoms

\-Summary of subjective and objective findings

\-What might have caused and/or perpetuated the problem?

\-What is the patient’s prognosis with treatment?

Prognosis includes:

\-Level of handicap

\-Self reliance

\-Level of motivation

\-Self efficacy

\-Kinesthetic awareness

Kinesthetic awareness:

\-Ask how their voice sounds different there, what did you do different, any body awareness you are looking for

Building self efficacy includes:

You can do this, do you see how you changed your voice, building their confidence to come back

Just because someone can change does not mean?

That they are willing or able to change

Where there is a high handicap level (more severe), the more?

Motivated they are to attend therapy

If both self efficacy (I can do it) and self reliance (I will stick to this) are high will they do better in therapy?

Yes

If level of motivation is high will they do better in therapy?

Yes

If kinesthetic awareness if high will they do better in therapy?

Yes

All goals need to be?

SMART

Long term goals are the?

Big picture, what the patient wants to achieve

Short term goals are?

The steps/tools to achieve the goal, specific measurable, attainable, relevant and time bound

Collaborative interaction and decision making:

\-ID what might be causing or contributing to problem

\-Educate and counsel

\-Ensure planned behavioral intervention is consistent with your patient’s goals

\-With permission from your pt. relay the information to anyone who serves as a support

Outcomes in voice assessment

\-Broad value of treatment measured by changes in vocal function as judged by patient/therapist

Efficacy in voice assessment

Whether the therapy controlled circumstances (study)

Efficacy in voice assessment

Whether the therapy works under “real world” settings- cost, patient, compliance

General Assessment Principles

What are we measuring

Reliable, repeatable and valid

Use sets of measure

Normative data when possible

Standardized scores when possible

Make results accessible and shareable to the patient

Connect the results to the patient

What is the best machine in voice therapy?

Your ear

Utility of Instrumental Measures:

Can the instrument-

* Detect a problem
* Assess the severity
* ID the source of the issues
* Serve as a tool for education or biofeedback

Pros of objective measures

* Insight into how the system is behaving
* Can get a global assessment of multiple aspects of a sound
* Documents vocal status in graphical, objective manner
* Easy to compare pre and post
* Can compare to norms
* Can be used to visual feedback or to explain the problem in a concrete way
* Indirect method of understanding

Cons of objective measures

* Can’t tell us what we hear


* Only as good as the user
* Costly
* Rely on interpretation which can be confusing
* Numerous and not always comparable
* Needs to be reliable (repetitive) and valid (measure what it is supposed to measure)

Limitations of perceptual voice assessment

\-Measures the product of the system; not how subsystems coordinate

* Can’t isolate the subsystems (breath from sound source)

\- Wide inter-rater variability

\-Somewhat subjective

\-Can’t compare to normative measures

\-Can’t judge small progressive changes over time

Clinical utility

\-Does the measure reflect the voice in singing or speech?

\-Is the measure reliable across trials?

\-Are there norms to compare your data to?

\-Is the protocol efficient?

Indirect Measures

\-Acoustic signal

\-Aerodynamic changes in pressure and flow

\-Visual images

\-We make inferences about laryngeal pathology from the results

What equipment do we need?

Microphone (ideally head mounted)

Digital recording equipment

Quiet recording space

Microphone

\-Keeps consistent distance from mouth

\-Angled from the center of the mouth

\-Cardioid or unidirectional

\-Avoid clipping

Digital recording equipment

\-Internal or external sound card

\-Sample at least 20KHz

\-16 Bits of amplitude quantization

Waveform

We are measuring irregularities and perturbations, can perceived perpetually as hoarseness, breathiness which is irregularities in the waveform

Measurement types

\-Spectral acoustic analysis (time-based)

\-Cepstral acoustic analysis (frequently-based)

Acoustic Characteristics

\-Fundamental frequency (F0)

\-Intensity (dB)

\-”Noise” and perturbation to periodicity

Frequency

Rate of vocal fold virbations-periods/seconds

Fundamental frequency (f0)

Lowest frequency (Hz) produced by oscillation of the vocal folds (perceptual: pitch)

Harmonics

Component frequencies of oscillations of waves, sometimes referred to as “overtones”

Intensity

Amplitude of signal

What are the spectral methods- sound perturbations (voice quality measures)?

Waveform and spectrogram

Waveforms include?

Jitter, shimmer and noise to harmonic ratio (NHR)

Jitter

\-Cycle to cycle differences in frequency or measures perturbation in frequency (pitch)

\-Affected by lack of control of vocal fold vibrations

\-Moderately correlated with hoarse and breathy vocal qualities

\-Normal range: 0.5-1.0% variation

\-Increased values-indicative of vocal pathology

Shimmer

\-Cycle to cycle differences in intensity (amplitude) or measures perturbations in amplitude

\-Normal variation

The degree of change (positive or negative) in atmospheric pressure (displacement) is caused by?

Sound waves (dB) acoustic energy of a sound

Noise to harmonic ratio (NHR)

\-Measures amount of turbulence (noise) compared to sinoidal energy in the voice signal

\-Analysis occurs for each frequency period and results are averaged over periods

\-The greater the value (higher the ratio), the more noise in the signal

\-Increased values, increased noise in ratio

Pros of Spectral Measures include:

\-More objective than auditory-perceptual assessment (less influences by clinician bias and order effect)

\-Easy to acquire with appropriate equipment

Cons of Spectral Measures include:

\-Output is very sensitive to variable such as dysphonic voices, pitch, voicing and intonation, correlations between spectral parameters and severity, quality and type of pathology have been shown to be moderate at best.

Cepstral Acoustic Analysis

\-Can extract f0, harmonics, amplitude and noise to harmonics without depending on cyclical (time based) boundaries

Cepstral Peak Prominence (CPP)

Uses logarithmic analysis and “frames” (rather than cycles) to determine differences between fundamental frequency and relative amplitude of harmonics without needing to identify oscillatory boundaries

In a typical voice the voice signal will be?

More prominent than the noise in the signal

The Cepstral/Spectral Index of Dysphonia (CSID)

The acoustic correlate to CAPE-V auditory perceptual VAS ratings that uses algorithms to capture voice parameters (pitch/frequency, loudness/intensity and quality) in multivariate manner using the we were away a year ago sentence and sustained vowel /a/

CSID does not take into account?

Listener experiences or articulatory characteristics of the speaker

What are considered the gold standards for what you should use to measure voice?

CPP and CSID

Running Speech

\-Cape V sentences

\-Spontaneous speech: how did you get here today?

\-Standardized passage: the rainbow passage

Sustained vowel

\-Comfortable pitch

\-High pitch

\-Low pitch

\-Soft as possible

\-Loud as possible

Acoustic analysis equipment

\-Analysis software

\-Common software

Analysis software

\-Use of standard (document) algorithms

\-In wide clinical use

\-Formally validated via comparison with other commonly used programs

Common softwave

\-Pentax medical computerized speech lab (multi-dimensional voice program)

\-Praat

Acoustic Analysis Apps

\-Advanced spectrum analyzer pro

\-Voice pitch analyzer

\-Sound analyzer

\-Sonneta voice monitor

\-Voice test

\-Voice analyst

\-Pitche analyzer

\-NOISH SLM

Aerodymanic analysis

\-Quantitative measures of laryngeal function in relation to pulmonary and articulatory systems

Assessment parameters to aerodynamic analysis:

Airflow, air pressure and airway resistance

Airflow

Estimates amount of air needed to sustain vocal fold oscillations using supraglottic airflow measured during vowel

Air pressure

Subglottal pressure required to initiate vocal fold oscillation, estimated by intraoral air pressure with voiceless stop consonant /p/

Airway resistance

Product of laryngeal airflow and subglottal pressure, quantifies the aerodynamic power needed to initiate and sustain vocal fold oscillation for a given glottal configuration

What are pressure measurement methods?

\-Phonatory aerodynamic system (PAS)

\-Subglottal pressure with speech (indirect)

Phonatory aerodynamic system (PAS)

In additional to subglottal pressure (with voiceless stop /p/), the PAS also measures

* Airflow (mean airflow on vowel)
* Laryngeal resistance (can use flow and pressure measurements to calculate)

Low cost measure methods

Stop watch, windmill spirometer, digital spirometer

Indirect measures of acoustics and aerodynamics should be?

Cross-referenced with your perceptual and visual voice and speech behaviors

In a noise to harmonic ratio the more noise in the ratio mean?

A more dysphonic voice

Harmonics are what we want to hear in the voice

True

Higher noise means?

More noise and we do not want this

Spectral methods are are less reliable for?

\-Dysphonic voices

Pros of Cepstral Measures

Both can be done with sustained voice and spontanous or running speech and is more accurate with dysphonic voices

Cons of Ceptral measures

Can still get inaccurate measurements if there is lots of background noise, inadequete signal to mic distanc, etc